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The reverberations from the Jan. 6 storming of the U.S. Capitol by supporters of President Donald Trump continue. A broad array of business groups, including many from the health industry, are halting contributions to Republicans in the House and Senate who voted against certifying the victory of President-elect Joe Biden. Meanwhile, Republicans in the House who have refused to wear masks or insisted on carrying weapons are being subjected to greater enforcement, including significant fines.
Away from the Capitol, the Trump administration has granted a first-in-the-nation waiver to Tennessee to turn its Medicaid program into a block grant, which would give the state potentially less federal money but more flexibility to structure the federal-state health program for those with low incomes. And in its waning days, the administration is moving to make its last-minute policies harder for Biden to undo.
This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Margot Sanger-Katz of The New York Times and Kimberly Leonard of Business Insider.
Among the takeaways from this week’s podcast:
- The decision by industry groups to cut their political contributions to some Republican lawmakers could reshape businesses’ relationships on Capitol Hill. But it’s still not clear if this announcement will affect the vast sums of political contributions that come through PACs and other unnamed sources, as well as individual contributions from corporate officials.
- The slow start of the covid vaccination campaign points to the tension between the need to steer the vaccine to people at high risk of contracting the disease and the concerns about wasting the precious medicine. Because the vaccines that have been approved for emergency use have a relatively short shelf life, some doses may go to waste if they are reserved for specific populations.
- The response to the vaccine among health care workers varies widely. In some areas, staffers are eager to get the shots, while in other places, some workers have been hesitant and the shots are going unused. And the federal government has not provided a strong public messaging campaign about the vaccines.
- The Trump administration’s announcement last week that it would move to convert Tennessee’s Medicaid program to a block grant program is raising concerns among advocates for the poor, who fear that the flexibility the state is gaining could lead to enrollees getting less care, especially since the state will get a hefty portion of any savings it finds in running the program.
- It may not be easy for the Biden administration to change this decision. Federal officials in recent weeks have been sending states, including Tennessee, letters to sign that could protect the Medicaid waivers they have received from the Trump administration and could serve as a legal guarantee that would require a long, difficult process to unwind.
- Mental health care may be a casualty of the coronavirus pandemic. As states look to balance their budgets after a year in which revenues were slashed, they may turn to cutting mental health care services provided through Medicaid and other programs.
Also this week, Rovner interviews KHN’s Victoria Knight, who wrote the latest KHN-NPR “Bill of the Month” feature — about an unusually large bill for in-network care. If you have an outrageous medical bill you’d like to share with us, you can do that here.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week that they think you should read too:
Julie Rovner: The Washington Post’s “Young ER doctors Risk Their Lives on the Pandemic’s Front Line. But They Struggle to Find Jobs,” by Ben Guarino
Margot Sanger-Katz: The New York Times’ “Why You’re Probably Not So Great at Risk Assessment,” by AC Shilton
Joanne Kenen: The Atlantic’s “Why Aren’t We Wearing Better Masks?” by Zeynep Tufekci and Jeremy Howard
Kimberly Leonard: Business Insider’s “I Was Offered a Covid Vaccine Even Though I’m Young and Healthy. Here’s How I Did It,” by Kimberly Leonard
To hear all our podcasts, click here.
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As healthcare spending continues to rise, so too does the inherent risk for bad actors to take advantage. Today, the United States is estimated to spend nearly 18 percent of its GDP, or $3.6 trillion, on healthcare, and is expected to increase to one-fifth of GDP within the next decade, according to the latest data. This alone provides ample motivation for fraud and abuse. While the full extent of healthcare fraud is difficult to measure,
The National Health Care Anti-Fraud Association (NHCAA) conservatively estimates that 3 percent – $68 billion – of all healthcare spending is lost to fraud each year. Others, such as the Federal Bureau of Investigation (FBI), estimate fraud accounts for up to 10 percent of healthcare expenditures.
Unfortunately, the COVID-19 pandemic has only accelerated the motivation for fraud and abuse amid the increased fear, confusion, and a relaxed regulatory environment. From fake cures to malware and illegitimate charities, fraudsters are taking advantage. Telehealth, which has experienced exponential growth aided by regulatory accommodations to facilitate its widespread adoption, is an area of particular concern. In turn, states and healthcare organizations must optimize their program integrity operations and telehealth strategy to stay protected amid healthcare’s new normal.
Greater Access Brings Greater Risk
The pandemic-driven expansion of telehealth has been profound in terms of enabling care access and continuity while reducing the risk of infection. When the Centers for Medicare and Medicaid Services (CMS) temporarily expanded telehealth coverage at the start of the pandemic, adoption soared to unprecedented levels.
According to a McKinsey report, providers have seen 50 to 175 times more patients through telehealth appointments compared to any year prior. At the same time, once-strict regulations governing telehealth services have been relaxed during the COVID-19 emergency, and the federal government has proposed to make permanent many of the regulatory changes initially meant to temporarily increase access to telehealth.
In parallel and perhaps unsurprisingly, there is a growing sentiment that telehealth is here to stay. According to a recent CynergisTek survey, 70 percent of consumers plan to continue using telehealth post-pandemic. From a provider perspective, new research from Bain & Company found that more than 80 percent of providers will continue to use telehealth as much or more than they do now.
All this considered, we must acknowledge the inherent risks of this technology. Telehealth has a poor track record for fraud, waste and abuse, with some of the largest healthcare fraud schemes involving telehealth providers. This September, for example, the Department of Justice announced the largest case of healthcare fraud in history, involving more than 300 individuals who submitted over $6 billion in fraudulent claims, with telehealth accounting for $4.5 billion of those claims.
With providers struggling to meet fluctuating demand amid unprecedented revenue shortfalls, improper billing practices — both intentional and inadvertent — are, to some degree, inevitable. Factor in hundreds of new telehealth codes and coding considerations as well as the overall stress on the healthcare system, and it is clear we must examine existing risk mitigation measures through a new, post-pandemic lens.
Strategies for Mitigating Telehealth Fraud & Abuse
For healthcare organizations and, specifically, special investigation units (SIUs) tasked with combatting fraud and abuse, the shift to telehealth adds an additional layer of complexity. Fortunately, there are strategies healthcare organizations can implement to successfully navigate the evolving landscape while strengthening the integrity of their operations for healthcare’s new normal.
Data visualization is a key component of an effective fraud investigation. Charts and graphs provide a clear representation of trends and outliers, including connections that could indicate a kickback or collusion scheme. Critical to the success of these tools, however, is the quality of the data that underlies them. Collecting sample data based on the appropriate modifiers and conducting thorough background research provides an accurate portrayal of events from which SIUs can clearly identify and pursue potential fraud schemes.
Integrating qualitative research into telehealth strategies is a great way to capture fraud at the source. When appropriate, conducting interviews with patients can validate whether services were in fact rendered as billed. For instance, a provider may bill for audio-only services as if they were delivered in an audio-visual capacity, resulting in an unjustifiably higher reimbursement rate. Similarly, using data visualization techniques to identify suspect trends, such as blanket billing or an implausibly high volume of services during a known low-demand period, can inform pointed questions for patients.
As we traverse this unprecedented territory, being on high alert for potential indicators of fraud and abuse is critical to protecting healthcare organizations and consumers. If something doesn’t make sense, whether clinically or in the context of the larger healthcare landscape, it is worth investigating. Understanding the limitations of telehealth and other key considerations surrounding its use will help to ensure we are maximizing the benefits of these services while mitigating their inherent risks.
Healthcare providers and patients alike have embraced telehealth during the COVID-19 crisis and, in doing so, confirmed what advocates have been saying for years — that telehealth promotes greater access to care. While ultimately good news for stakeholders across the healthcare spectrum, the environment we find ourselves in today has also created new avenues for fraudsters to take advantage. As telehealth becomes an inseparable part of the healthcare ecosystem, we are quickly learning how to identify telehealth fraud schemes, and, more importantly, strategies to mitigate the risks they post to integrity and security in the space.
About Gary Call, M.D.
Gary Call, M.D., is senior vice president and Chief Medical Officer at HMS, where he leads the company’s clinical program development and execution. Dr. Call has more than 25 years of experience in the practice of medicine and managed care. Dr. Call graduated from the University of Washington School of Medicine and completed his residency training at the University of Utah. He is a board-certified family physician.
What You Should Know:
– Net Health acquires post-acute market analytics platform PointRight to deepen the company’s analytics capabilities, post-acute presence, and support for SNF networks.
Health, a provider of cloud-based software for specialty medical providers
across the continuum of care, today announced that it has acquired
PointRight Inc., a leading provider of
analytics and data-driven tools for the post-acute market. The acquisition adds
to Net Health’s expanding investments in analytics capabilities, which include
the recent acquisition of Tissue Analytics in April 2020 and the earlier
acquisition of Focus on Therapeutic Outcomes (FOTO).
Unlock the Power of Advanced Analytics for Post-Acute
Founded in 1995, PointRight provides analytics that shows a 360⁰ view of long-term and post-acute (LTPAC) facility performance and clinical outcomes. Equipped with these insights, LTPAC Provider and Payers can lower rehospitalization rates, improve clinical outcomes, and build and manage high-performing networks. Today, close to 2,400 SNFs use PointRight’s advanced analytics and data-driven decision support tools to further their clinical, financial, and operational objectives.
SNFs use PointRight to improve the accuracy of their reimbursement and regulatory submissions and to enhance overall performance in readmissions, quality, and outcomes, including more accurate and compliant patient assessments, reduced rehospitalization rates, and optimized care transitions.
More recently, health systems, ACOs, payers, and real estate investment trusts (REIT) have relied on PointRight to provide insight into the health of their SNF networks and to identify areas for improvement.
Acquisition Expands Net Health’s
Market Share in Growing Post-Acute Market
acquisition of PointRight expands Net Health’s position and scale in the
growing post-acute market. Additionally, the acquisition will enable Net
Health’s broad roster of hospital clients to better manage their skilled
nursing facility (SNF) networks and support outcomes measurement and performance
improvement in Medicare Advantage and managed Medicaid programs. As part of the
acquisition, Net Health
plans to fully integrate PointRight staff to accelerate the delivery of new
analytics solutions and expand the availability of PointRight to Net Health’s
customers and markets.
“Through PointRight, Net Health will significantly expand how we support SNFs and their health system, accountable care organization (ACO), payer and REIT partners,” said Josh Pickus, Net Health’s Chief Executive Officer. “It also strengthens our growing analytics capabilities by providing insights into post-acute performance, which enables providers and payers to align around value-based care initiatives.”
Financial details of the acquisition
were not disclosed.
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SACRAMENTO, Calif. — The coronavirus pandemic doomed Gov. Gavin Newsom’s ambitious plans last year to combat homelessness, expand behavioral health services and create a state agency to control soaring health care costs.
But even as the pandemic continues to rage, California’s Democratic governor said Friday he plans to push forward with those goals in the coming year, due to a rosier budget forecast buoyed by higher tax revenue from wealthy Californians who have fared relatively well during the crisis.
Newsom’s $227.2 billion budget blueprint also prioritizes billions to safely reopen K-12 schools shuttered by the pandemic, $600 payments for nearly 4 million low-income Californians — in addition to federal stimulus payments — and coronavirus relief grants and tax credits for hard-hit small businesses.
However, his 2021-22 fiscal year spending plan does not include additional public health money for local health departments steering California’s pandemic response, which have been chronically underfunded. He vowed to support cities and counties by boosting state testing and contact tracing capacity, speeding vaccination efforts and funding state-run surge hospitals that take overflow patients.
Newsom said Friday his budget reflects a “pandemic-induced reality” with investments aimed at spurring California’s economic recovery by helping businesses and people living in poverty. Wealth and income disparities, he added, “must be addressed.”
But Democrats in control of the state legislature, county leaders and social justice groups say that will be difficult to achieve because Newsom’s spending plan does not sufficiently fund health and social safety-net programs.
And without additional public health money, local leaders worry California will not be able to adequately control the spread of the virus.
“County public health is drowning,” said Graham Knaus, executive director of the California State Association of Counties. “We are triaging right now between testing, contact tracing and vaccination, and it’s impacting the response to the pandemic.”
Newsom’s budget proposal is the first step in a months-long negotiation process with the Democratic-controlled legislature, which has until June 15 to adopt the state budget that takes effect July 1. Lawmakers have become increasingly frustrated with the governor’s response to the pandemic, including his unilateral spending decisions in response to the emergency. Newsom is also facing a burgeoning recall effort, backed by heavyweight Republicans such as former San Diego Mayor Kevin Faulconer, who is considering challenging Newsom in the 2022 California gubernatorial election.
Newsom said he expects to make some tough calls on spending even though the state anticipates a $15 billion budget surplus for the coming fiscal year, largely because a state fiscal analysis projected deficits in subsequent years.
“While we are enjoying the fruits of a lot of one-time energy and surplus, it’s not permanent and we have to be mindful of over-committing,” Newsom said, explaining why he didn’t include funding to expand Medicaid to more unauthorized immigrants.
Some lawmakers say they will nonetheless press Newsom to use higher-than-expected revenues — and perhaps seek new taxes — to expand health coverage to more Californians.
The following health care proposals factor heavily into Newsom’s 2021-22 budget proposal.
Newsom committed $4.4 billion in his budget to vaccine distribution, increased testing, contact tracing and other short-term pandemic expenses. Because that spending is related to the public health emergency, the state expects at least 75% to be reimbursed by the federal government and insurance payments.
He also proposed $52 million to fund costs at state-run surge hospitals, including support staff. And he is asking lawmakers to sign off on a covid relief package that would provide funding before the start of the fiscal year in July. It would include $2 billion to help school districts reopen classrooms to in-person instruction beginning in February by paying for protective equipment, ventilation systems and adequate testing. It would also commit billions to economic recovery, such as stimulus payments for individuals, and grants and tax credits for struggling small businesses.
Newsom also wants to increase the budget for the Department of Industrial Relations by $23 million to fund up to 113 additional workplace inspectors at the California Division of Occupational Safety and Health to police health order violations at businesses and enforce workplace safety laws.
Spending for Medi-Cal, the state’s Medicaid program for low-income residents, is expected to grow in the coming year because of the economic impact of the pandemic — as is its enrollment. The program has roughly 13 million enrollees, or about one-third of the state population.
In the coming year, Newsom will also press forward with a major overhaul of Medi-Cal, through a project called CalAIM, to provide new benefits emphasizing mental health care and substance use treatment, and pay for some nontraditional costs such as housing assistance. The hope is the program would divert homeless and other vulnerable people away from expensive emergency room care and keep them out of jail.
State Medi-Cal officials estimate the program would cost $1.1 billion for the first year. The state is working with the federal Centers for Medicare & Medicaid Services to obtain approval for the program.
Newsom also wants to expand Medi-Cal benefits to cover over-the-counter cold medicine and blood glucose monitors for people with diabetes. His budget includes $95 million for a major expansion of telehealth services that would permanently provide higher payments for virtual doctor visits.
Controlling Health Care Costs
Newsom is proposing a new state agency, the Office of Health Care Affordability, which he said would help control health care costs. He budgeted $63 million over the next three years for the office, which would set health care cost targets for the health care industry — along with financial penalties for failing to meet future targets.
Powerful health industry groups said they are still assessing whether they will support the proposal. But some expressed concern last year when Newsom floated the idea. Doctors and hospitals routinely fight proposals in Sacramento that might limit their revenue.
Newsom acknowledged Friday the task would be “tough.”
Battling Homelessness and Food Insecurity
Newsom is proposing a one-time infusion of $1.75 billion to battle homelessness.
Of that, Newsom said, $750 million would help counties purchase hotels and transform them into permanent housing for chronically homeless people. Another $750 million would allow counties to purchase facilities to treat people with mental illness or substance use disorders. And $250 million would help counties purchase and renovate homes for low-income older people.
Newsom’s budget also includes $30 million to help overwhelmed food banks and emergency food assistance programs.
Lawmakers said they plan to negotiate for even more funding for homelessness and safety-net programs.
“We absolutely need to significantly increase our investment to address homelessness because the need is so intense,” said Assembly member David Chiu (D-San Francisco). “And I don’t think there’s a single legislator who isn’t incredibly concerned about the food insecurity we’re seeing: lines around the block for food banks in what should be the wealthiest state in the country.”
Expanding Health Coverage
Newsom did not include money in his proposed budget to expand Medi-Cal to unauthorized immigrants age 65 and older. He had previously promised to fund the proposal, estimated to cost $350 million per year once fully implemented, but he said Friday the state cannot afford to commit to ongoing costs with a projected budget deficit starting in fiscal year 2022-23. California already offers full Medicaid benefits for income-eligible unauthorized immigrants up to age 26.
Some lawmakers and health care advocates countered that providing health insurance for undocumented immigrants would save lives and reduce costs, especially during the pandemic, and vowed to continue to fight for the expansion.
“To say we are disappointed is describing it very lightly,” said Orville Thomas, a lobbyist with the California Immigrant Policy Center. “These are Californians dying and getting sick at disproportionate rates during covid.”
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Trinity Health, a national Catholic tax-exempt chain, wants to close Mercy Hospital and Medical Center on Chicago’s Near South Side by May 31. Last month, in an unusual move, the Illinois Health Facilities & Services Review Board unanimously denied Trinity permission to close the 412-bed facility, which predominantly serves Black and other minority patients on Medicaid.
The board members said they feared the closure would limit access to care for nearly 60,000 South Side residents, forcing them to travel nearly 7 miles to the closest facility with an emergency room, intensive care unit and birthing center. It also would cost the community about 2,000 hospital jobs.
Urban hospitals in low-income areas of Los Angeles, Philadelphia, San Francisco, Washington, D.C., and other cities and suburbs face similar financial squeezes. Inner-city facilities like Mercy struggle to survive on lean payment rates from Medicaid and to compete with financially robust hospitals that mostly serve well-paying, privately insured patients.
So far, no one has come up with a politically and financially viable solution for strengthening safety-net health providers in low-income urban communities. “The sad fact is market location is everything,” said Lawton Robert Burns, a professor of health care management at the University of Pennsylvania, who studied the controversial closure of Hahnemann University Hospital in Philadelphia in 2019. “No offense to poor people, but there are economic factors that hospitals can’t control.”
But it is far from clear that a government board can stop a hospital from going out of business. “It’s really difficult in a capitalist country to tell a private company you have to continue to lose money,” said Dr. Linda Rae Murray, a member of the health facilities board and former Trinity Health board member who teaches health policy at the University of Illinois-Chicago.
Trinity, which operates 92 hospitals in 22 states, seems determined to push forward with its plans to close the hospital. It has deep pockets, with $31.9 billion in total assets. It reported revenue of $18.8 billion last year, and a profit of 2.3% in the most recent quarter. Trinity executives told the health facilities board in December that Mercy loses nearly $39 million a year and that they could not find any buyers for the hospital — Chicago’s oldest, chartered in 1852. They also reminded the board that state lawmakers rejected Mercy’s 2019 $1 billion proposal to merge with three other South Side hospitals and build a new hospital facility and several new clinics with $520 million in state aid.
Trinity declined to make anyone available for an interview for this article.
Trinity has said it will try again to get approval to shut Mercy at the facilities review board’s Jan. 26 meeting. It has offered to replace the hospital with a $13 million clinic offering just diagnostic and urgent care — but no primary care physician services. Critics of that proposal say the clinic, while helpful, would not be an adequate replacement for the hospital because it would not provide access to the full range of needed services.
“We can’t have these mega-hospital companies that are getting a property tax exemption for providing charity care closing a safety-net hospital in the middle of a pandemic,” said former Illinois Gov. Pat Quinn, a Democrat who spearheaded a 2013 deal to save Roseland Hospital, another embattled facility on Chicago’s South Side. “I’d tell the Trinity executives, ‘You’re not doing this to Chicago. We’ll work with you to put together a bigger deal.’”
The obvious long-term solution is richer Medicaid funding for safety-net hospitals, effective partnerships between public and private providers and firm commitments by financially strong hospital companies, including academic medical centers, to expand services in low-income communities. For instance, some say state and local officials should prod Trinity to use the resources of its Loyola University Medical Center in west suburban Chicago to bolster Mercy.
Hospitals are required to get a certificate of need for closure from the facilities review board, according to a new state law. But state officials’ actions are limited when seeking to enforce a decision to keep a facility open.
The state could levy a fine of up to $10,000 for not complying with the board’s decision, plus an additional $10,000 a month while the hospital continues to operate. But that’s a trivial amount for a big company like Trinity.
The state also could halt Medicaid and other public payments to Mercy. But that would be counterproductive, hastening the hospital’s demise since nearly half of Mercy’s inpatient revenue and 35% of its outpatient revenue comes from Medicaid, according to state data.
A final source of leverage is in Trinity’s ownership of three other hospitals in the Chicago area: Loyola, Gottlieb Memorial Hospital and MacNeal Hospital. The state could threaten Trinity’s property-tax exemption as a charitable organization. That’s an approach favored by Quinn, who cited a previous legal challenge to the tax-exempt status of the Carle Foundation Hospital in Urbana, Illinois.
No matter what the state does, Trinity can find ways to shut down Mercy. It could argue that even as Mercy is meeting the state requirement to continue to treat patients, it must close critical services like the emergency department or the birthing center because it lacks funding or staff to maintain adequate quality of care, said Juan Morado Jr., a Chicago health care lawyer who formerly served as general counsel for the facilities review board. The new law permits closing only one hospital department every six months.
While the state presses to keep the hospital open, Mercy also could suffer from attrition. When there’s talk of closing a hospital, physicians, nurses and other staffers may start leaving for other jobs. Whether Trinity seeks to refill positions is critical.
“There are things the owner can do to trickle the hospital down to nothing,” said Dr. David Ansell, senior vice president for community health equity at Rush University Medical Center in Chicago, who opposes shuttering Mercy. “There is a drip, drip, drip of negativity, and at some point people vote with their feet.”
The Chicago area has been through a similar battle recently. Pipeline Health, a private-equity investment firm, bought Westlake Hospital in suburban Melrose Park and two other local hospitals from hospital chain Tenet Healthcare in 2019. Pipeline quickly announced it was closing Westlake, a 230-bed hospital — even though it had promised the state it would keep it open for at least two years.
That controversial move prompted the Illinois legislature to give the facilities review board new authority to deny permission for future hospital closures, which the board lacked for Westlake.
Yet, the Westlake saga may point to a better solution for Mercy. In early 2020, the state and federal governments renovated the Westlake facility so it could be used as an overflow site for covid-19 patients. It wasn’t needed, but the updates led to strong interest from companies in purchasing and reopening the hospital, particularly for behavioral health inpatient services.
State Rep. Kathleen Willis, a Democrat who co-sponsored the 2019 bill to let the facilities review board say no to hospital closures, said a deal to buy and reopen Westlake likely will be announced within the next few weeks.
Any deal to save Mercy likely will require more money from Trinity, more commitment from other providers to offer a full range of hospital and medical services in the area, and significant increases in state and federal funding.
“Every hospital CEO has to worry about the bottom line of their business,” Ansell said. “But big organizations like Trinity need to come up with a better solution than the wholesale shutdown of an anchor institution that will leave communities bereft.”
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With just a dozen days left in power, the Trump administration on Friday approved a radically different Medicaid financing system in Tennessee that for the first time would give the state broad authority in running the health insurance program for the poor in exchange for capping its annual federal funding.
The approval is a 10-year “experiment.” Instead of the open-ended federal funding that rises with higher enrollment and health costs, Tennessee will instead get an annual block grant. The approach has been pushed for decades by conservatives who say states too often chafe under strict federal guidelines about enrollment and coverage and can find ways to provide care more efficiently.
The approval, however, faces an uncertain future because the incoming Biden administration is likely to oppose such a move. But to unravel it, officials would need to set up a review that includes a public hearing.
Meanwhile, the changes in Tennessee will take months to implement because they need final legislative approval, and state officials must negotiate quality of care targets with the administration.
TennCare, the state’s Medicaid program, said the block grant system would give it unprecedented flexibility to decide who is covered and what services it will pay for.
It said the new arrangement would allow the state to keep part of the money it saves from operating the program more efficiently. Trump administration officials said the approach adds incentive for the state to save money, unlike the current system, in which increased state spending is matched with more federal dollars. If Medicaid enrollment grows, the state can secure additional federal funding. If enrollment drops, it will get less money.
“This groundbreaking waiver puts guardrails in place to ensure appropriate oversight and protections for beneficiaries, while also creating incentives for states to manage costs while holding them accountable for improving access, quality and health outcomes,” said Seema Verma, administrator of the Centers for Medicare & Medicaid Services. “It’s no exaggeration to say that this carefully crafted demonstration could be a national model moving forward.”
Opponents, including most advocates for low-income Americans, say the approach will threaten care for the 1.4 million people in TennCare, which includes children, pregnant women and the disabled. Federal funding covers two-thirds of the cost of the program.
Michele Johnson, executive director of the Tennessee Justice Center, said the block grant approval is a step backward for the state’s Medicaid program.
“No other state has sought a block grant, and for good reason. It gives state officials a blank check and creates financial incentives to cut health care to vulnerable families,” she said.
Democrats have fought back block grant Medicaid proposals since the Reagan administration and most recently in 2018 as part of Republicans’ failed effort to repeal and replace major parts of the Affordable Care Act. Even some key Republicans opposed the idea because it would cut billions in funding to states that would make it harder to help the poor.
Implementing block grants via an executive branch action rather than getting Congress to amend Medicaid law is also likely to be met with court challenges.
The block grant approval comes as Medicaid enrollment is at its highest ever level.
More than 76 million Americans are covered by the state-federal health program, a million more than when the Trump administration took charge in 2017. Enrollment has jumped by more than 5 million in the past year as the economy slumped with the pandemic.
Medicaid, part of President Lyndon B. Johnson’s “Great Society” initiative of the 1960s, is an entitlement program in which the government pays each state a certain percentage of the cost of care for anyone eligible for the health coverage. As a result, the more money states spend on Medicaid, the more they get from Washington.
Under the approved demonstration, CMS will work with Tennessee to set spending targets that will increase at a fixed amount each year.
The plan includes a “safety valve” to increase federal funding due to unexpected increases in enrollment.
“The safety valve will maintain Tennessee’s commitment to enroll all eligible Tennesseans with no reduction in today’s benefits for beneficiaries,” CMS said in a statement.
Tennessee has committed to maintaining coverage for eligible beneficiaries and existing services.
In exchange for taking on this financing approach, the state will receive a range of operating flexibilities from the federal government, as well as up to 55% of the savings generated on an annual basis when spending falls below the aggregate spending cap and the state meets certain quality targets, yet to be determined.
The state can spend that money on various health programs for residents, including areas that Medicaid funding typically doesn’t cover, such as improving transportation and education and employment.
The 10-year waiver is unusual, but the Trump administration has approved such long-term experiments in recent years to give states more flexibility.
Tennessee is one of 12 states that have not approved expanding Medicaid under the Affordable Care Act that’s left tens of thousands of working adults without health insurance.
“The block grant is just another example of putting politics ahead of health care during this pandemic,” said Johnson of the Tennessee Justice Center. “Now is absolutely not the time to waste our energy and resources limiting who can access health care.”
State officials applauded the approval.
“It’s a legacy accomplishment,” said Tennessee Gov. Bill Lee, a Republican. “This new flexibility means we can work toward improving maternal health coverage and clearing the waiting list for developmentally disabled.”
“This means we will be able to make additional investments in TennCare without reduction in services and provider cuts.”
KHN chief Washington correspondent Julie Rovner contributed to this report.
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What You Should Know:
– COVID-19 care deferrals lead to three major boomerang
conditions that payers and providers must proactively address in 2021,
according to a newly released report by Prealize.
– COVID-19’s hidden victims—those who avoided or deferred
care during the pandemic—will increasingly return to the healthcare system, and
many will be diagnosed with new conditions at more advanced stages. Healthcare
leaders must act now to keep this boomerang from driving worse outcomes and
Prealize, an artificial
intelligence (AI)-enabled predictive analytics company, today announced the
publication of a new report that explores key medical conditions payers and
providers should proactively address in 2021. Healthcare utilization for
preventive care, chronic care, and emergent care significantly decreased in
2020 due to the COVID-19
pandemic, which will result in an influx of newly diagnosed and later stage
conditions in 2021. Prealize’s
2021 State of Health Market Report: Bracing for Impact identifies the
top at-risk conditions based on Prealize’s claims analysis and predictive
Report Background & Methodology
Many procedures and diagnoses fell significantly in 2020,
with several dropping nearly 50% below 2019 levels between March and June. Total
healthcare utilization fell 23% between March and August 2020, compared to the
same time period in 2019.
To explore the full scope of healthcare utilization and
procedural declines in 2020, and assess how those declines will impact
patients’ health and payers’ pocketbooks in 2021, Prealize Health conducted an
analysis of claims data from nearly 600,000 patients between March 2020 and
Prealize identified the three predicted conditions likely to
see the largest increase in healthcare utilization in 2021:
1. Cardiac diagnoses will increase by 18% for ischemic
heart disease and 14% for congestive heart failure
These increases will be driven by 2020 healthcare
utilization declines, for example, patients deferring family medicine and
internal medicine visits. These visits, which help flag cardiac problems and
prevent them from escalating, declined 24% between March and August of 2020.
“Cardiac illnesses are some of the most serious and
potentially fatal, so delays in diagnosis can lead to significant adverse
outcomes,” said Gordon Norman, MD, Prealize’s Chief Medical Officer.
“Without early recognition and appropriate intervention, rates of patient
hospitalization and death are likely to increase, as will associated costs of
2. Cancer diagnoses will increase by 23%
Similar to cardiac screening trends, significant declines in
2020 cancer screenings will be a key driver of this increase, with 46% fewer
colonoscopies and 32% fewer mammograms performed between March and August 2020
than during that same time period in 2019.
“Cancer doesn’t stop developing or progressing because
there’s a pandemic,” said Ronald A. Paulus, MD, President and CEO at RAPMD
Strategic Advisors, Immediate Past President and CEO of Mission Health, and one
of the medical experts interviewed for the report. “In 2021, when patients
who deferred care ultimately receive their diagnoses, their cancer sadly may be
more advanced. In addition, an increase in newly diagnosed patients may make it
harder for some patients to access care and specialists—particularly for those
patients who are insured by Medicaid or lack insurance altogether.”
3. Fractures will increase by 112%
This finding, based on combined analysis of osteoporosis
risk and fall risk, is particularly troubling for the elderly patient
A key driver of increased fractures in 2021 is the number of
postponed elective orthopedic procedures in 2020, such as hip and knee
replacements. These procedural delays are likely to decrease mobility, and
therefore, increase risk of fractures from falls.
“In elderly patients, fractures are very serious events
that too often lead to decreased overall mobility and quality of life,”
said Norman. “As a result, patients may suffer from physical follow-on
events like pulmonary embolisms, and behavioral health concerns like increased
Why It Matters
“These predictions are daunting, but the key is that providers and payers take action now to mitigate their effects,” said Prealize CEO Linda T. Hand. “It’s going to be critical to gain insight into populations to understand their risk at an individual level, build trust, and treat their conditions as early as possible to improve outcomes. The COVID-19 pandemic has challenged every aspect of our healthcare system, but the way to get ahead of these challenges in 2021 will be to proactively identify and address patients most at risk. We’re going to see proactive care become an important driver for success next year, as providers and payers seek to mitigate unnecessary and expensive procedures that result from 2020’s decreased medical utilization. The right predictive analytics partner will be critical to providers and payers being able to take the right course of action.”
Algunos llegan tan enfermos que van directo a cuidados intensivos. Muchos no sobreviven.
“Vivimos una pesadilla constante”, dijo Prendkowski mientras trataba a pacientes con coronavirus en el Hospital Mount Sinai, fundado a principios del siglo XX para atender a los inmigrantes más pobres. “Ojalá salgamos pronto de esto”.
La enfermera cree que algunas muertes, y mucho sufrimiento, podrían haberse evitado si estas personas hubieran tenido un tratamiento regular para todo tipo de condiciones crónicas —asma, diabetes, enfermedades del corazón— que pueden empeorar COVID-19.
Y ahora se siente esperanzada.
En medio del brote del mortal virus que ha afectado de manera desproporcionada a las comunidades hispanas, Illinois se convirtió recientemente en el primer estado de la nación en extender el seguro médico público a todos los adultos mayores no ciudadanos de bajos ingresos, incluso si son indocumentados.
Defensores de los inmigrantes esperan que inspire a otros estados a hacer lo mismo. De hecho, legisladores demócratas de California están presionando para expandir su Medicaid a todos los inmigrantes indocumentados del estado.
“Hacer esto durante la pandemia muestra nuestro compromiso con la expansión y ampliación del acceso a la atención de salud. Es un gran primer paso”, señaló Graciela Guzmán, directora de campaña de Healthy Illinois, que promueve la cobertura universal en el estado.
Muchos inmigrantes indocumentados sin cobertura de salud no van al médico. Ese fue el caso de Victoria Hernández, una limpiadora de casas de 68 años que vive en West Chicago, Illinois. La mujer, nativa de la Ciudad de México dijo que, cuando no tenía seguro, simplemente no iba al médico.
Soportaba cualquier dolencia hasta que encontró un programa de caridad que la ayudó a tratar su prediabetes. Dijo que tiene la intención de inscribirse en el nuevo plan estatal una vez que tenga más información.
“Estoy muy agradecida por el nuevo programa”, explicó a través de un traductor que trabaja para DuPage Health Coalition, una organización sin fines de lucro que coordina la atención de caridad para personas sin seguro médico como Hernández en el condado de DuPage, el segundo más poblado del estado. “Sé que ayudará a mucha gente como yo. Sé que tendrá buenos resultados, muy, muy buenos resultados”.
Primero, Healthy Illinois intentó ampliar los beneficios de Medicaid a todos los inmigrantes de bajos ingresos, pero los legisladores decidieron empezar con un programa más pequeño, que cubre a adultos mayores de 65 años o más que son indocumentados, o que han sido residentes permanentes, tienen tarjeta verde, por menos de cinco años (este grupo no califica para seguro de salud auspiciado por el gobierno).
Los participantes deben tener ingresos que estén en o por debajo del nivel de pobreza federal, que es de $12,670 para un individuo o $17,240 para una pareja. Cubre servicios como visitas al hospital y al médico, medicamentos recetados, y atención dental y oftalmológica (aunque no estancias en centros de enfermería), sin costo para el paciente.
La nueva norma continúa la tendencia de expandir la cobertura de salud del gobierno a los inmigrantes sin papeles.
El año pasado, California fue el primero en ofrecer cobertura pública a los adultos indocumentados, cuando amplió la elegibilidad para su programa Medi-Cal a todos los residentes de bajos ingresos menores de 26 años.
Según la ley federal, las personas indocumentadas generalmente no son elegibles para Medicare, Medicaid que no es de emergencia y el mercado de seguros de salud de la Ley de Cuidado de Salud a Bajo Precio (ACA). Los estados que ofrecen cobertura a esta población lo hacen usando sólo fondos estatales.
Se estima que en Illinois viven 3,986 adultos mayores indocumentados, según un estudio del Centro Médico de la Universidad de Rush y el grupo de demógrafos de Chicago Rob Paral & Associates; y se espera que el número aumente a 55,144 para 2030. El informe también encontró que el 16% de los inmigrantes de Illinois de 55 años o más viven en la situación de pobreza, en comparación con el 11% de la población nacida en el país.
Dado que la administración saliente de Trump ha promovido duras medidas migratorias, sectores del activismo pro inmigrante temen que haya miedo a inscribirse en el nuevo programa porque podría afectar la capacidad de obtener la residencia o la ciudadanía en el fututo, y trabajan para asegurarles que no lo hará.
“Illinois cuenta con un legado de ser un estado que acepta al recién llegado y de proteger la privacidad de los inmigrantes”, señaló Andrea Kovach, abogada que trabaja en equidad en la salud en el Shriver Center for Poverty Law en Chicago.
Se espera que la normativa cubra inicialmente de 4,200 a 4,600 inmigrantes mayores, a un costo aproximado de entre $46 millones a $50 millones al año, según John Hoffman, vocero del Departamento de Salud y Servicios Familiares de Illinois.
Algunos representantes estatales republicanos criticaron la expansión de la cobertura, diciendo que era imprudente hacerlo en un momento en que las finanzas de Illinois sufren por la pandemia. En una declaración condenando el presupuesto estatal de este año, el Partido Republicano de Illinois lo denominó “atención de la salud gratuito para los inmigrantes ilegales”.
Pero los defensores de la nueva política sostienen que muchos inmigrantes sin papeles pagan impuestos sin ser elegibles para programas como Medicare y Medicaid, y que gastar por adelantado en cuidados preventivos ahorra dinero, a largo plazo, al reducir el número de personas que esperan para buscar tratamiento hasta que es una emergencia.
Para Delia Ramírez, representante estatal de Illinois, ampliar la cobertura de salud a todos los adultos mayores de bajos ingresos es personal. A la demócrata de Chicago la inspira su tío, un inmigrante de 64 años que no tiene seguro.
Dijo que intentó que la legislación cubriera a las personas de 55 años o más, ya que la gran mayoría de los indocumentados no son personas mayores (señaló que muchos de los inmigrantes mayores —2,7 millones, según estimaciones del gobierno— obtuvieron el estatus legal con la ley de amnistía federal de 1986).
Un mayor número de inmigrantes más jóvenes también pueden estar sin seguro. En los Centros de Salud Esperanza, uno de los mayores proveedores de atención médica para inmigrantes de Chicago, el 31% de los pacientes de 65 años o más carece de cobertura, en comparación con el 47% de los de 60 a 64 años, según Jeffey McInnes, que supervisa el acceso de los pacientes a las clínicas.
Ramírez dijo que su tío la llamó después de ver las noticias sobre la nueva legislación en la televisión en español. Contó que su tío ha vivido en el país por cuatro décadas y ha trabajado para que sus cuatro hijos fueran a la universidad. También padece asma, diabetes e hipertensión, lo que lo hace de alto riesgo para COVID-19.
“Yo le dije: ‘Tío, todavía no. Pero cuando cumplas 65 años, finalmente tendrás atención médica, si es que aún no hemos conseguido legalizarte”, recordó Ramírez, emocionada, durante una reciente entrevista telefónica.
“Así que es un recordatorio para mí de que, en primer lugar, fue una gran victoria para nosotros y ha significado la vida o una segunda oportunidad de vida para muchas personas”, dijo. “Pero también significa que todavía tenemos un largo camino por recorrer para hacer de la atención de salud un verdadero derecho humano en el estado, y en la nación”.
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“We’re in a bad dream all the time,” she said during a recent day treating coronavirus patients at Mount Sinai Hospital, which was founded in the early 20th century to care for the city’s poorest immigrants. “I can’t wait to wake up from this.”
Prendkowski believes some of the death and suffering could have been avoided if more of these people had regular treatment for the types of chronic conditions — asthma, diabetes, heart disease — that can worsen covid. She now sees a new reason for hope.
Amid a deadly virus outbreak that has disproportionately stricken Latino communities, Illinois recently became the first state to provide public health insurance to all low-income noncitizen seniors, even if they’re in the country illegally. Advocates for immigrants expect it will inspire other states to do the same, building on efforts to cover undocumented children and young adults. Currently, Democratic legislators in California are pushing to expand coverage to all low-income undocumented immigrants there.
“The fact that we’re going to do this during the pandemic really shows our commitment to expansion and broadening health care access. It’s an amazing first step in the door,” said Graciela Guzmán, campaign director for Healthy Illinois, a group that advocates for universal coverage.
Undocumented immigrants without health insurance often skip care. That was the case for Victoria Hernandez, 68, a house cleaner who lives in West Chicago, a suburb. The Mexico City native said she had avoided going to the doctor because she didn’t have coverage. Eventually, she found a charity program to help her get treatment, including for her prediabetes. She said she intends to enroll in the new state plan.
“I’m very thankful for the new program,” she said through a translator who works for the DuPage Health Coalition, a nonprofit that coordinates charity care for the uninsured in DuPage County, the state’s second-most populous. “I know it will help a lot of people like me.”
Healthy Illinois pushed state lawmakers to offer health benefits to all low-income immigrants. But the legislature opted instead for a smaller program that covers people 65 and older who are undocumented or have been legal permanent residents, also known as green card holders, for less than five years. (These groups don’t typically qualify for government health insurance.) Participants must have an income at or below the federal poverty level, which is $12,670 for an individual or $17,240 for a couple. It covers services like hospital and doctor visits, prescription drugs, and dental and vision care (though not stays in nursing facilities), at no cost to the patient.
The new policy continues a trend of expanding government health coverage to undocumented immigrants.
Illinois was the first state to cover children’s care — a handful of states and the District of Columbia have since followed suit — and organ transplants for unauthorized immigrants. In 2019, California became the first to offer public coverage to adults in the country illegally when it opened eligibility for its Medi-Cal program to all low-income residents under age 26.
Under federal law, undocumented people are generally not eligible for Medicare, nonemergency Medicaid and the Affordable Care Act’s health insurance marketplace. The states that do cover this population get around that by using only state funds.
An estimated 3,986 undocumented seniors live in Illinois, according to a study by Rush University Medical Center and the Chicago demographer group Rob Paral & Associates — but that number is expected to grow to 55,144 by 2030. The report also found that 16% of Illinois immigrants 55 or older live in poverty, compared with 11% of the native-born population.
Given the outgoing Trump administration’s crackdown on immigration, some advocates worry that people will be afraid to enroll in the insurance because it could affect their ability to obtain residency or citizenship. Andrea Kovach, senior attorney for health care justice at the Shriver Center on Poverty Law in Chicago, said she and others are working to assure immigrants they don’t need to worry. Because the new program is state-funded, federal guidance suggests it is not subject to the “public charge” rule designed to keep out immigrants who might end up on public assistance.
“Illinois has a legacy of being a very welcoming state and protecting immigrants’ privacy,” Kovach said.
The Illinois policy is initially expected to cover 4,200 to 4,600 immigrant seniors, at an approximate cost of $46 million to $50 million a year, according to John Hoffman, a spokesperson for the Illinois Department of Healthcare and Family Services. Most of them would likely be undocumented.
Some Republicans criticized the coverage expansion, saying it was reckless at a time when Illinois’ finances are being shredded by the pandemic. The Illinois Republican Party deemed it “free healthcare for illegal immigrants.”
But proponents contend that many unauthorized immigrants pay taxes without being eligible for programs like Medicare and Medicaid, and that spending on preventive care saves money in the long run by cutting down on more expensive treatment for emergencies.
State Rep. Delia Ramirez, a Chicago Democrat who helped shepherd the legislation, advocated for a more expansive plan. She was inspired by her uncle, a 64-year-old immigrant who has asthma, diabetes and high blood pressure but no insurance. He has been working in the country for four decades.
She wanted the policy to apply to people 55 and older, since the vast majority of those who are undocumented are not seniors (she noted that a lot of older immigrants — 2.7 million, according to government estimates — obtained legal status under the 1986 federal amnesty law).
The real impact of this plan will likely be felt in years to come. At Esperanza Health Centers, one of Chicago’s largest providers of health care to immigrants, 31% of patients 65 and older lack coverage, compared with 47% of those 60 to 64, according to Jeffrey McInnes, who oversees patient access there.
Ramirez said her uncle called her after seeing news of the legislation on Spanish-language TV.
“And I said to him, ‘Tío, not yet. But when you turn 65, you’ll finally have health care, if we still can’t help you legalize,’” Ramirez recalled, choking up during a recent phone interview.
“So it is a reminder to me that, one, it was a major victory for us and it has meant life or a second chance at life for many people,” she said. “But it is also a reminder to me that we still have a long way to go in making health care truly a human right in the state and, furthermore, the nation.”
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Under his insurance plan, the former flight attendant and customer service instructor owed $500 in copayments every month for the drug and an additional $250 every three months for lab work and clinic visits.
Luckily for Howard, his doctor at Las Vegas’ Huntridge Family Clinic, which specializes in LGBTQ care, enrolled him in a clinical trial that covered his medication and other costs in full.
“If I hadn’t been able to get into the trial, I wouldn’t have kept taking PrEP,” said Howard, 68, using the shorthand term for “preexposure prophylaxis.” Taken daily, these drugs — like Truvada — are more than 90% effective at preventing infection with HIV.
Starting this month, most people with private insurance will no longer have to decide whether they can afford to protect themselves against HIV. Most health plans must begin to cover the drugs then without charging consumers anything out-of-pocket (some plans already began doing so last year).
Drugs in this category — Truvada, Descovy and, newly available, a generic version of Truvada — received an “A” recommendation by the U.S. Preventive Services Task Force. Under the Affordable Care Act, preventive services that receive an “A” or “B” rating by the task force, a group of medical experts in prevention and primary care, must be covered by most private health plans without making members share the cost, usually through copayments or deductibles. Only plans that are grandfathered under the health law are exempt.
The task force recommended PrEP for people at high risk of HIV infection, including men who have sex with men and injection drug users.
In the United States, more than 1 million people live with HIV, and nearly 40,000 new HIV cases are diagnosed every year. Yet fewer than 10% of people who could benefit from PrEP are taking it. One key reason is that out-of-pocket costs can exceed $1,000 annually, according to a study published in the American Journal of Public Health last year. Required periodic blood tests and doctor visits can add hundreds of dollars to the cost of the drug, and it’s not clear if insurers are required to pick up all those costs.
“Cost sharing has been a problem,” said Michael Crews, policy director at One Colorado, an advocacy group for the LGBTQ community. “It’s not just getting on PrEP and taking a pill. It’s the lab and clinical services. That’s a huge barrier for folks.”
Whether you’re shopping for a new plan during open enrollment or want to check out what your current plan covers, here are answers to questions you may have about the new preventive coverage requirement.
Q: How can people find out whether their health plan covers PrEP medications without charge?
The plan’s list of covered drugs, called a formulary, should spell out which drugs are covered, along with details about which drug tier they fall into. Drugs placed in higher tiers generally have higher cost sharing. That list should be online with the plan documents that give coverage details.
Sorting out coverage and cost sharing can be tricky. Both Truvada and Descovy can also be used to treat HIV, and if they are taken for that purpose, a plan may require members to pay some of the cost. But if the drugs are taken to prevent HIV infection, patients shouldn’t owe anything out-of-pocket, no matter which tier they are on.
In a recent analysis of online formularies for plans sold on the ACA marketplaces, Carl Schmid, executive director of the HIV + Hepatitis Policy Institute, found that many plans seemed out of compliance with the requirement to cover PrEP without cost sharing this year.
But representatives for Oscar and Kaiser Permanente, two insurers that were called out in the analysis for lack of compliance, said the drugs are covered without cost sharing in plans nationwide if they are taken to prevent HIV. Schmid later revised his analysis to reflect Oscar’s coverage.
Coverage and cost-sharing information needs to be transparent and easy to find, Schmid said.
“I acted like a shopper of insurance, just like any person would do,” he said. “Even when the information is correct, [it’s so] difficult to find [and there’s] no uniformity.”
It may be necessary to call the insurer directly to confirm coverage details if information on the website is unclear.
Q: Are all three drugs covered without cost sharing?
Health plans have to cover at least one of the drugs in this category — Descovy and the brand and generic versions of Truvada — without cost sharing. People may have to jump through some hoops to get approval for a specific drug, however. For example, Oscar plans sold in 18 states cover the three PrEP options without cost sharing. The generic version of Truvada doesn’t require prior authorization by the insurer. But if someone wants to take the name-brand drug, they have to go through an approval process. Descovy, a newer drug, is available without cost sharing only if people are unable to use Truvada or its generic version because of clinical intolerance or other issues.
Q: What about the lab work and clinical visits that are necessary while taking PrEP? Are those services also covered without cost sharing?
That is the thousand-dollar question. People who are taking drugs to prevent HIV infection need to meet with a clinician and have bloodwork every three months to test for HIV, hepatitis B and sexually transmitted infections, and to check their kidney function.
The task force recommendation doesn’t specify whether these services must also be covered without cost sharing, and advocates say federal guidance is necessary to ensure they are free.
“If you’ve got a high-deductible plan and you’ve got to meet it before those services are covered, that’s going to add up,” said Amy Killelea, senior director of health systems and policy at the National Alliance of State & Territorial AIDS Directors. “We’re trying to emphasize that it’s integral to the intervention itself.”
A handful of states have programs that help people cover their out-of-pocket costs for lab and clinical visits, generally based on income.
There is precedent for including free ancillary care as part of a recommended preventive service. After consumers and advocates complained, the Centers for Medicare & Medicaid Services (CMS) clarified that under the ACA removing a polyp during a screening colonoscopy is considered an integral part of the procedure and patients shouldn’t be charged for it.
CMS officials declined to clarify whether PrEP services such as lab work and clinical visits are to be covered without cost sharing as part of the preventive service and noted that states generally enforce such insurance requirements. “CMS intends to contact state regulators, as appropriate, to discuss issuer’s compliance with the federal requirements and whether issuers need further guidance on which services associated with PrEP must be covered without cost sharing,” the agency said in a statement.
Q: What if someone runs into roadblocks getting a plan to cover PrEP or related services without cost sharing?
If an insurer charges for the medication or a follow-up visit, people may have to go through an appeals process to fight it.
“They’d have to appeal to the insurance company and then to the state if they don’t succeed,” said Nadeen Israel, vice president of policy and advocacy at the AIDS Foundation of Chicago. “Most people don’t know to do that.”
Q: Are uninsured people also protected by this new cost-sharing change for PrEP?
Unfortunately, no. The ACA requirement to cover recommended preventive services without charging patients applies only to private insurance plans. People without insurance don’t benefit. Gilead, which makes both Truvada and Descovy, has a patient assistance program for the uninsured.
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Dr. Paul Hain, Chief Medical Officer of GoHealth
Telehealth is Here to Stay in 2021
Prior to the pandemic, telehealth was a limited ad-hoc service with geographic and provider restrictions. However, with both the pandemic restrictions on face to face interactions and a relaxation of governmental regulations, telehealth utilization has significantly increased from thousands of visits in a week to well over a million in the Medicare population. What we’ve learned is that telehealth allows patients, especially high-risk populations like seniors, to connect with their doctors in a safe and efficient way. Telehealth is valuable for many types of visits, mostly clearly ones that involve mental health or physical health issues that do not require a physical exam or procedure. It’s an efficient modality for both the member and provider.
With the growing popularity of telehealth services, we may see permanent changes in regulatory standards. Flexible regulatory standards, such as being able to use platforms like FaceTime or Skype, would lower the barrier to entry for providers to offer telehealth and also encourage adoption, especially among seniors. Second, it’s likely we’ll see an emergence of providers with aligned incentives around value, such as in many Medicare Advantage plans, trying very hard to encourage utilization with their members so that they get the right care at the right time. In theory, the shift towards value-based care will allow better care and lower costs than the traditional fee for service model. If we are able to evolve regulatory and payment environments, providers have an opportunity to grow these types of services into 2021 to improve patient wellness and health outcomes.
Dr. Salvatore Viscomi, Chief Medical Officer, GoodCell
2021 will be the year of patient controlled-health
The COVID-19 pandemic brought the realities of a global-scale health event – and our general lack of preparedness to address it – to the forefront. People are now laser-focused on how they can protect themselves and their families against the next inevitable threat. On top of this, social distancing and isolation accelerated the development and use of digital health tools, from wellness trackers to telehealth and virtual care, most of which can be accessed from the comfort of our homes. The convergence of these two forces is poised to make 2021 the year for patient-controlled health, whereby health decisions are not dictated by – but rather made in consultation with – a healthcare provider, leveraging insights and data pulled from a variety of health technology tools at people’s fingertips.
Anish Sebastian, CEO of Babyscripts
Telemedicine was the finger in the dyke at the beginning of pandemic panic, with healthcare providers grabbing whatever came to hand — encouraged by relaxed HIPAA regulations — to keep the dam from breaking. But as the dust settles, telemedicine is emerging as the commodity that it is, and value-add services are going to be the differentiating factors in an increasingly competitive marketplace. Offerings like remote patient monitoring and asynchronous communication, initially considered as “nice-to-haves,” are becoming standard offerings as healthcare providers see their value for continuous care beyond Covid.
Daniel Kivatinos, COO and Co-Founder of DrChrono
Telehealth visits are going to supersede in-person visits as time goes on.
Because of COVID-19, the world changed and Medicare and Medicaid, as well as other insurers, started paying out for telehealth visits. Telemedicine will continue to grow at a very quick rate, and verticals like mental health (psychology and psychiatry) and primary care fit perfectly into the telemedicine model, for tasks like administering prescription refills (ePrescribing) and ordering labs. Hyperlocal medical care will also move towards more of a telemedicine care team experience. Patients that are homebound families with young children or people that just recently had surgery can now get instant care when they need it. Location is less relevant because patients can see a provider from anywhere.
Dennis McLaughlin VP of Omni Operations + Product at ibi
Virtual Healthcare is Here to Stay (House Calls are Back)
This new normal however is going to put significant pressure on the data support and servicing requirements to do it effectively. As more services are offered to patients outside of established clinical locations, it also means there will be more opportunity to collect data and a higher degree of dependence on interoperability. Providers are going to have to up their game from just providing and recording facts to passing on critical insight back into these interactions to maximize the benefits to the patient.
Sarahjane Sacchetti, CEO at Cleo
Virtual care (of all types) will become a lasting form of care: The vastly accelerated and broadened use of virtual care spurred by the pandemic will become permanent. Although it started with one-off check-ins or virtual mental health coaching, 2021 will see the continued rise in the use and efficacy of virtual care services once thought to be in-person only such as maternity, postpartum, pediatric, and even tutoring. Employers are taking notice of this shift with 32% indicating that expanded virtual health services are a top priority, and this number will quickly rise as employers look to offer flexible and convenient benefits in support of employees and to drive productivity.
Omri Shor, CEO of Medisafe
Digital expansion: The pandemic has accelerated patient technology adoption, and innovation remains front-and-center for healthcare in 2021. Expect to see areas of telemedicine and digital health monitoring expand in new and novel ways, with increased uses in remote monitoring and behavioral health. CMS has approved telehealth for a number of new specialties and digital health tools continue to gain adoption among healthcare companies, drug makers, providers, and patients.
Digital health companions will continue to become an important tool to monitor patients, provide support, and track behaviors – while remaining socially distant due to the pandemic. Look for crossover between medical care, drug monitoring, and health and wellness – Apple
Watch has already previewed this potential with heart rate and blood oxygen monitoring. Data output from devices will enable support to become more personalized and triggered by user behavior.
Kelli Bravo, Vice President, Healthcare and Life Sciences, Pegasystems
The COVID-19 pandemic has not only changed and disrupted our lives, it has wreaked havoc on the entire healthcare industry at a scale we’ve never seen before. And it continues to alter almost every part of life across the globe. The way we access and receive healthcare has also changed as a result of social distancing requirements, patient concerns, provider availability, mobile capabilities, and newly implemented procedures at hospitals and healthcare facilities.
For example, hospitals and providers are postponing elective procedures again to help health systems prepare and reserve ICU beds amid the latest COVID-19 resurgence. While level of care is always important, in some areas, the inability to access a healthcare provider is equally concerning. And these challenges may become even more commonplace in the post-COVID-19 era. One significant transformation to help with the hurdle is telehealth, which went from a very small part of the care offering before the health crisis to one that is now a much more accepted way to access care.
As the rise in virtual health continues to serve consumers and provide a personalized and responsive care experience, healthcare consumers expect support services and care that are also fast and personalized – with digital apps, instant claims settlements, transparency, and advocacy. And to better help serve healthcare consumers, the industry has an opportunity to align with digital transformation that offers a personalized and responsive experience.
Brooke LeVasseur, CEO of AristaMD
Issues pertaining to the COVID-19 pandemic will continue to be front-and-center in 2021. Every available digital tool in the box will have to be employed to ensure patients with non-COVID related issues are not forgotten as we try to free up in-person space and resources for those who cannot get care in any other setting. Virtual front doors, patient/physician video and eConsults, which connect providers to collaborate electronically, will be part of a broadening continuum of care – ultimately aimed at optimizing every valuable resource we have.
Bret Larsen, CEO and Co-Founder, eVisit
By the end of 2021, virtual care paths will be fairly ubiquitous across the continuum of care, from urgent care and EDs to specialty care, all to serve patients where they are – at home and on mobile devices. This will be made possible through virtualized end-to-end processes that integrate every step in patient care from scheduling, waiting rooms, intake and patient queuing, to interpretation services, referral management, e-prescribe, billing and analytics, and more.
Laura Kreofsky, Vice President for Advisory & Telehealth for Pivot Point Consulting
2020 has been the year of rapid telehealth adoption and advancement due to the COVID pandemic. According to CDC reports, telehealth utilization spiked as much as 154% in late March compared to the same period in 2019. While usage has moderated, it’s clear telehealth is now an instrumental part of healthcare delivery. As provider organizations plan for telehealth in 2021 and beyond, we are going to have to expect and deliver a secure, scalable infrastructure, a streamlined patient experience and an approach that maximizes provider efficiency, all while seeing much-needed vendor consolidation.
Jeff Lew, SVP of Product Management, Nextech
Earlier this year, CMS enacted new rules to provide practices with the flexibility they need to use telehealth solutions in response to COVID-19, during which patients also needed an alternative to simply visiting the office. This was the impetus to the accelerated acceptance of telehealth as a means to both give and receive care. Specialty practices, in particular, are seeing successful and positive patient experiences due to telehealth visits. Dermatology practices specifically standout and I expect the strong adoption will continue to grow and certainly be the “new normal.” In addition, innovative practices that have embraced this omni-channel approach to delivering care are also establishing this as a “new normal” by selectively using telehealth visits for certain types of encounters, such as post-op visits or triaging patients. This gives patients a choice and the added convenience that comes with it and, in some cases, increases patient volume for the practice.
Kimberly Powell, Vice President & General Manager, NVIDIA Healthcare
Federated Learning: The clinical community will increase their use of federated learning approaches to build robust AI models across various institutions, geographies, patient demographics, and medical scanners. The sensitivity and selectivity of these models are outperforming AI models built at a single institution, even when there is copious data to train with. As an added bonus, researchers can collaborate on AI model creation without sharing confidential patient information. Federated learning is also beneficial for building AI models for areas where data is scarce, such as for pediatrics and rare diseases.
AI-Driven Drug Discovery: The COVID-19 pandemic has put a spotlight on drug discovery, which encompasses microscopic viewing of molecules and proteins, sorting through millions of chemical structures, in-silico methods for screening, protein-ligand interactions, genomic analysis, and assimilating data from structured and unstructured sources. Drug development typically takes over 10 years, however, in the wake of COVID, pharmaceutical companies, biotechs, and researchers realize that acceleration of traditional methods is paramount. Newly created AI-powered discovery labs with GPU-accelerated instruments and AI models will expedite time to insight — creating a computing time machine.
Smart Hospitals: The need for smart hospitals has never been more urgent. Similar to the experience at home, smart speakers and smart cameras help automate and inform activities. The technology, when used in hospitals, will help scale the work of nurses on the front lines, increase operational efficiency, and provide virtual patient monitoring to predict and prevent adverse patient events.
Omri Shor, CEO of Medisafe
Healthcare policy: Expect to see more moves on prescription drug prices, either through a collaborative effort among pharma groups or through importation efforts. Pre-existing conditions will still be covered for the 135 million Americans with pre-existing conditions.
The Biden administration has made this a central element of this platform, so coverage will remain for those covered under ACA. Look for expansion or revisions of the current ACA to be proposed, but stalled in Congress, so existing law will remain largely unchanged. Early feedback indicates the Supreme Court is unlikely to strike down the law entirely, providing relief to many during a pandemic.
Brent D. Lang, Chairman & Chief Executive Officer, Vocera Communications
The safety and well-being of healthcare workers will be a top priority in 2021. While there are promising headlines about coronavirus vaccines, we can be sure that nurses, doctors, and other care team members will still be on the frontlines fighting COVID-19 for many more months. We must focus on protecting and connecting these essential workers now and beyond the pandemic.
Modernized PPE Standards
Clinicians should not risk contamination to communicate with colleagues. Yet, this simple act can be risky without the right tools. To minimize exposure to infectious diseases, more hospitals will rethink personal protective equipment (PPE) and modernize standards to include hands-free communication technology. In addition to protecting people, hands-free communication can save valuable time and resources. Every time a nurse must leave an isolation room to answer a call, ask a question, or get supplies, he or she must remove PPE and don a fresh set to re-enter. With voice-controlled devices worn under PPE, the nurse can communicate without disrupting care or leaving the patient’s bedside.
Voice-controlled solutions can also help new or reassigned care team members who are unfamiliar with personnel, processes, or the location of supplies. Instead of worrying about knowing names or numbers, they can use simple voice commands to connect to the right person, group, or information quickly and safely. In addition to simplifying clinical workflows, an intelligent communication system can streamline operational efficiencies, improve triage and throughput, and increase capacity, which is all essential to hospitals seeking ways to recover from 2020 losses and accelerate growth.
Michael Byczkowski, Global Vice President, Head of Healthcare Industry at SAP,
New, targeted healthcare networks will collaborate and innovate to improve patient outcomes.
We will see many more touchpoints between different entities ranging from healthcare providers and life sciences companies to technology providers and other suppliers, fostering a sense of community within the healthcare industry. More organizations will collaborate based on existing data assets, perform analysis jointly, and begin adding innovative, data-driven software enhancements. With these networks positively influencing the efficacy of treatments while automatically managing adherence to local laws and regulations regarding data use and privacy, they are paving the way for software-defined healthcare.
Smart hospitals will create actionable insights for the entire organization out of existing data and information.
Medical records as well as operational data within a hospital will continue to be digitized and will be combined with experience data, third-party information, and data from non-traditional sources such as wearables and other Internet of Things devices. Hospitals that have embraced digital are leveraging their data to automate tasks and processes as well as enable decision support for their medical and administrative staff. In the near future, hospitals could add intelligence into their enterprise environments so they can use data to improve internal operations and reduce overhead.
Curt Medeiros, President and Chief Operating Officer of Ontrak
As health care costs continue to rise dramatically given the pandemic and its projected aftermath, I see a growing and critical sophistication in healthcare analytics taking root more broadly than ever before. Effective value-based care and network management depend on the ability of health plans and providers to understand what works, why, and where best to allocate resources to improve outcomes and lower costs. Tied to the need for better analytics, I see a tipping point approaching for finally achieving better data security and interoperability. Without the ability to securely share data, our industry is trying to solve the world’s health challenges with one hand tied behind our backs.
G. Cameron Deemer, President, DrFirst
Like many business issues, the question of whether to use single-vendor solutions or a best-of-breed approach swings back and forth in the healthcare space over time. Looking forward, the pace of technology change is likely to swing the pendulum to a new model: systems that are supplemental to the existing core platform. As healthcare IT matures, it’s often not a question of ‘can my vendor provide this?’ but ‘can my vendor provide this in the way I need it to maximize my business processes and revenues?
This will be more clear with an example: An EHR may provide a medication history function, for instance, but does it include every source of medication history available? Does it provide a medication history that is easily understood and acted upon by the provider? Does it provide a medication history that works properly with all downstream functions in the EHR? When a provider first experiences medication history during a patient encounter, it seems like magic.
After a short time, the magic fades to irritation as the incompleteness of the solution becomes more obvious. Much of the newer healthcare technologies suffer this same incompleteness. Supplementing the underlying system’s capabilities with a strongly integrated third-party system is increasingly going to be the strategy of choice for providers.
Angie Franks, CEO of Central Logic
In 2021, we will see more health systems moving towards the goal of truly operating as one system of care. The pandemic has demonstrated in the starkest terms how crucial it is for health systems to have real-time visibility into available beds, providers, transport, and scarce resources such as ventilators and drugs, so patients with COVID-19 can receive the critical care they need without delay. The importance of fully aligning as a single integrated system that seamlessly shares data and resources with a centralized, real-time view of operations is a lesson that will resonate with many health systems.
Expect in 2021 for health systems to enhance their ability to orchestrate and navigate patient transitions across their facilities and through the continuum of care, including post-acute care. Ultimately, this efficient care access across all phases of care will help healthcare organizations regain revenue lost during the historic drop in elective care in 2020 due to COVID-19.
In addition to elevating revenue capture, improving system-wide orchestration and navigation will increase health systems’ bed availability and access for incoming patients, create more time for clinicians to operate at the top of their license, and reduce system leakage. This focus on creating an ‘operating as one’ mindset will not only help health systems recover from 2020 losses, it will foster sustainable and long-term growth in 2021 and well into the future.
John Danaher, MD, President, Global Clinical Solutions, Elsevier
COVID-19 has brought renewed attention to healthcare inequities in the U.S., with the disproportionate impact on people of color and minority populations. It’s no secret that there are indicative factors, such as socioeconomic level, education and literacy levels, and physical environments, that influence a patient’s health status. Understanding these social determinants of health (SDOH) better and unlocking this data on a wider scale is critical to the future of medicine as it allows us to connect vulnerable populations with interventions and services that can help improve treatment decisions and health outcomes. In 2021, I expect the health informatics industry to take a larger interest in developing technologies that provide these kinds of in-depth population health insights.
Jay Desai, CEO and co-founder of PatientPing
2021 will see an acceleration of care coordination across the continuum fueled by the Centers for Medicare and Medicaid Services (CMS) Interoperability and Patient Access rule’s e-notifications Condition of Participation (CoP), which goes into effect on May 1, 2021. The CoP requires all hospitals, psych hospitals, and critical access hospitals that have a certified electronic medical record system to provide notification of admit, discharge, and transfer, at both the emergency room and the inpatient setting, to the patient’s care team. Due to silos, both inside and outside of a provider’s organization, providers miss opportunities to best treat their patients simply due to lack of information on patients and their care events.
This especially impacts the most vulnerable patients, those that suffer from chronic conditions, comorbidities or mental illness, or patients with health disparities due to economic disadvantage or racial inequity. COVID-19 exacerbated the impact on these vulnerable populations. To solve for this, healthcare providers and organizations will continue to assess their care coordination strategies and expand their patient data interoperability initiatives in 2021, including becoming compliant with the e-notifications Condition of Participation.
Kuldeep Singh Rajput, CEO and founder of Biofourmis
Driven by CMS’ Acute Hospital at Home program announced in November 2020, we will begin to see more health systems delivering hospital-level care in the comfort of the patient’s home–supported by technologies such as clinical-grade wearables, remote patient monitoring, and artificial intelligence-based predictive analytics and machine learning.
A randomized controlled trial by Brigham Health published in Annals of Internal Medicine earlier this year demonstrated that when compared with usual hospital care, Home Hospital programs can reduce rehospitalizations by 70% while decreasing costs by nearly 40%. Other advantages of home hospital programs include a reduction in hospital-based staffing needs, increased capacity for those patients who do need inpatient care, decreased exposure to COVID-19 and other viruses such as influenza for patients and healthcare professionals, and improved patient and family member experience.
Jake Pyles, CEO, CipherHealth
The disappearance of the hospital monopoly will give rise to a new loyalty push
Healthcare consumerism was on the rise ahead of the pandemic, but the explosion of telehealth in 2020 has effectively eliminated the geographical constraints that moored patient populations to their local hospitals and providers. The fallout has come in the form of widespread network leakage and lost revenue. By October, in fact, revenue for hospitals in the U.S. was down 9.2% year-over-year. Able to select providers from the comfort of home and with an ever-increasing amount of personal health data at their convenience through the growing use of consumer-grade wearable devices, patients are more incentivized in 2021 to choose the provider that works for them.
After the pandemic fades, we’ll see some retrenchment from telehealth, but it will remain a mainstream care delivery model for large swaths of the population. In fact, post-pandemic, we believe telehealth will standardize and constitute a full 30% to 40% of interactions.
That means that to compete, as well as to begin to recover lost revenue, hospitals need to go beyond offering the same virtual health convenience as their competitors – Livango and Teladoc should have been a shot across the bow for every health system in 2020. Moreover, hospitals need to become marketing organizations. Like any for-profit brand, hospitals need to devote significant resources to building loyalty but have traditionally eschewed many of the cutting-edge marketing techniques used in other industries. Engagement and personalization at every step of the patient journey will be core to those efforts.
Marc Probst, former Intermountain Health System CIO, Advisor for SR Health by Solutionreach
Healthcare will fix what it’s lacking most–communication.
Because every patient and their health is unique, when it comes to patient care, decisions need to be customized to their specific situation and environment, yet done in a timely fashion. In my two decades at one of the most innovative health systems in the U.S., communication, both across teams and with patients continuously has been less than optimal. I believe we will finally address both the interpersonal and interface communication issues that organizations have faced since the digitization of healthcare.”
Rich Miller, Chief Strategy Officer, Qgenda
2021 – The year of reforming healthcare: We’ve been looking at ways to ease healthcare burdens for patients for so long that we haven’t realized the onus we’ve put on providers in doing so. Adding to that burden, in 2020 we had to throw out all of our playbooks and become masters of being reactive. Now, it’s time to think through the lessons learned and think through how to be proactive. I believe provider-based data will allow us to reformulate our priorities and processes. By analyzing providers’ biggest pain points in real-time, we can evaporate the workflow and financial troubles that have been bothering organizations while also relieving providers of their biggest problems.”
Robert Hanscom, JD, Vice President of Risk Management and Analytics at Coverys
Data Becomes the Fix, Not the Headache for Healthcare
The past 10 years have been challenging for an already overextended healthcare workforce. Rising litigation costs, higher severity claims, and more stringent reimbursement mandates put pressure on the bottom line. Continued crises in combination with less-than-optimal interoperability and design of health information systems, physician burnout, and loss of patient trust, have put front-line clinicians and staff under tremendous pressure.
Looking to the future, it is critical to engage beyond the day to day to rise above the persistent risks that challenge safe, high-quality care on the frontline. The good news is healthcare leaders can take advantage of tools that are available to generate, package, and learn from data – and use them to motivate action.
Steve Betts, Chief of Operations and Products at Gray Matter Analytics
Analytics Divide Intensifies: Just like the digital divide is widening in society, the analytics divide will continue to intensify in healthcare. The role of data in healthcare has shifted rapidly, as the industry has wrestled with an unsustainable rate of increasing healthcare costs. The transition to value-based care means that it is now table stakes to effectively manage clinical quality measures, patient/member experience measures, provider performance measures, and much more. In 2021, as the volume of data increases and the intelligence of the models improves, the gap between the haves and have nots will significantly widen at an ever-increasing rate.
Substantial Investment in Predictive Solutions: The large health systems and payors will continue to invest tens of millions of dollars in 2021. This will go toward building predictive models to infuse intelligent “next best actions” into their workflows that will help them grow and manage the health of their patient/member populations more effectively than the small and mid-market players.
Jennifer Price, Executive Director of Data & Analytics at THREAD
The Rise of Home-based and Decentralized Clinical Trial Participation
In 2020, we saw a significant rise in home-based activities such as online shopping, virtual school classes and working from home. Out of necessity to continue important clinical research, home health services and decentralized technologies also moved into the home. In 2021, we expect to see this trend continue to accelerate, with participants receiving clinical trial treatments at home, home health care providers administering procedures and tests from the participant’s home, and telehealth virtual visits as a key approach for sites and participants to communicate. Hybrid decentralized studies that include a mix of on-site visits, home health appointments and telehealth virtual visits will become a standard option for a range of clinical trials across therapeutic areas. Technological advances and increased regulatory support will continue to enable the industry to move out of the clinic and into the home.
Doug Duskin, President of the Technology Division at Equality Health
Value-based care has been a watchword of the healthcare industry for many years now, but advancement into more sophisticated VBC models has been slower than anticipated. As we enter 2021, providers – particularly those in fee-for-service models who have struggled financially due to COVID-19 – and payers will accelerate this shift away from fee-for-service medicine and turn to technology that can facilitate and ease the transition to more risk-bearing contracts. Value-based care, which has proven to be a more stable and sustainable model throughout the pandemic, will seem much more appealing to providers that were once reluctant to enter into risk-bearing contracts. They will no longer be wondering if they should consider value-based contracting, but how best to engage.
Brian Robertson, CEO of VisiQuate
Continued digitization and integration of information assets: In 2021, this will lead to better performance outcomes and clearer, more measurable examples of “return on data, analytics, and automation.
Digitizing healthcare’s complex clinical, financial, and operational information assets: I believe that providers who are further in the digital transformation journey will make better use of their interconnected assets, and put the healthcare consumer in the center of that highly integrated universe. Healthcare consumer data will be studied, better analyzed, and better predicted to drive improved performance outcomes that benefit the patient both clinically and financially.
Some providers will have leapfrog moments: These transformations will be so significant that consumers will easily recognize that they are receiving higher value. Lower acuity telemedicine and other virtual care settings are great examples that lead to improved patient engagement, experience and satisfaction. Device connectedness and IoT will continue to mature, and better enable chronic disease management, wellness, and other healthy lifestyle habits for consumers.
Kermit S. Randa, CEO of Syntellis Performance Solutions
Healthcare CEOs and CFOs will partner closely with their CIOs on data governance and data distribution planning. With the massive impact of COVID-19 still very much in play in 2021, healthcare executives will need to make frequent data-driven – and often ad-hoc — decisions from more enterprise data streams than ever before. Syntellis research shows that healthcare executives are already laser-focused on cost reduction and optimization, with decreased attention to capital planning and strategic growth. In 2021, there will be a strong trend in healthcare organizations toward new initiatives, including clinical and quality analytics, operational budgeting, and reporting and analysis for decision support.
Dr. Calum Yacoubian, Associate Director of Healthcare Product & Strategy at Linguamatics
As payers and providers look to recover from the damage done by the pandemic, the ability to deliver value from data assets they already own will be key. The pandemic has displayed the siloed nature of healthcare data, and the difficulty in extracting vital information, particularly from unstructured data, that exists. Therefore, technologies and solutions that can normalize these data to deliver deeper and faster insights will be key to driving economic recovery. Adopting technologies such as natural language processing (NLP) will not only offer better population health management, ensuring the patients most in need are identified and triaged but will open new avenues to advance innovations in treatments and improve operational efficiencies.
Prior to the pandemic, there was already an increasing level of focus on the use of real-world data (RWD) to advance the discovery and development of new therapies and understand the efficacy of existing therapies. The disruption caused by COVID-19 has sharpened the focus on RWD as pharma looks to mitigate the effect of the virus on conventional trial recruitment and data collection. One such example of this is the use of secondary data collection from providers to build real-world cohorts which can serve as external comparator arms.
This convergence on seeking value from existing RWD potentially affords healthcare providers a powerful opportunity to engage in more clinical research and accelerate the work to develop life-saving therapies. By mobilizing the vast amount of data, they will offer pharmaceutical companies a mechanism to positively address some of the disruption caused by COVID-19. This movement is one strategy that is key to driving provider recovery in 2021.
Rose Higgins, Chief Executive Officer of HealthMyne
Precision imaging analytics technology, called radiomics, will increasingly be adopted and incorporated into drug development strategies and clinical trials management. These AI-powered analytics will enable drug developers to gain deeper insights from medical images than previously capable, driving accelerated therapy development, greater personalization of treatment, and the discovery of new biomarkers that will enhance clinical decision-making and treatment.
Dharmesh Godha, President and CTO of Advaiya
Greater adoption and creative implementation of remote healthcare will be the biggest trend for the year 2021, along with the continuous adoption of cloud-enabled digital technologies for increased workloads. Remote healthcare is a very open field. The possibilities to innovate in this area are huge. This is the time where we can see the beginning of the convergence of personal health aware IoT devices (smartwatches/ temp sensors/ BP monitors/etc.) with the advanced capabilities of the healthcare technologies available with the monitoring and intervention capabilities for the providers.
Simon Wu, Investment Director, Cathay Innovation
Healthcare Data Proves its Weight in Gold in 2021
Real-world evidence or routinely stored data from hospitals and claims, being leveraged by healthcare providers and biopharma companies along with those that can improve access to data will grow exponentially in the coming year. There are many trying to build in-house, but similar to autonomous technology, there will be a separate set of companies emerge in 2021 to provide regulated infrastructure and have their “AWS” moment.
Kyle Raffaniello, CEO of Sapphire Digital
2021 is a clear year for healthcare price transparency
Over the past year, healthcare price transparency has been a key topic for the Trump administration in an effort to lower healthcare costs for Americans. In recent months, COVID-19 has made the topic more important to patients than ever before. Starting in January, we can expect the incoming Biden administration to not only support the existing federal transparency regulations but also continue to push for more transparency and innovation within Medicare. I anticipate that healthcare price transparency will continue its momentum in 2021 as one of two Price Transparency rules takes effect and the Biden administration supports this movement.
Dennis McLaughlin VP of Omni Operations + Product at ibi
Social Determinants of Health Goes Mainstream: Understanding more about the patient and their personal environment has a hot topic the past two years. Providers and payers’ ability to inject this knowledge and insight into the clinical process has been limited. 2021 is the year it gets real. It’s not just about calling an uber anymore. The organizations that broadly factor SDOH into the servicing model especially with virtualized medicine expanding broadly will be able to more effectively reach vulnerable patients and maximize the effectiveness of care.
Joe Partlow, CTO at ReliaQuest
The biggest threat to personal privacy will be healthcare information: Researchers are rushing to pool resources and data sets to tackle the pandemic, but this new era of openness comes with concerns around privacy, ownership, and ethics. Now, you will be asked to share your medical status and contact information, not just with your doctors, but everywhere you go, from workplaces to gyms to restaurants. Your personal health information is being put in the hands of businesses that may not know how to safeguard it. In 2021, cybercriminals will capitalize on rapid U.S. telehealth adoption. Sharing this information will have major privacy implications that span beyond keeping medical data safe from cybercriminals to wider ethics issues and insurance implications.
Jimmy Nguyen, Founding President at Bitcoin Association
Blockchain solutions in the healthcare space will bring about massive improvements in two primary ways in 2021.
Firstly, blockchain applications will for the first time facilitate patients owning, managing, and even monetizing their personal health data. Today’s healthcare information systems are incredibly fragmented, with patient data from different sources – be they physicians, pharmacies, labs, or otherwise – kept in different silos, eliminating the ability to generate a holistic view of patient information and restricting healthcare providers from producing the best health outcomes.
Healthcare organizations are growing increasingly aware of the ways in which blockchain technology can be used to eliminate data silos, enable real-time access to patient information, and return control to patients for the use of their personal data – all in a highly-secure digital environment. 2021 will be the year that patient data goes blockchain.
Secondly, blockchain solutions can ensure more honesty and transparency in the development of pharmaceutical products. Clinical research data is often subject to questions of integrity or ‘hygiene’ if data is not properly recorded, or worse, is deliberately fabricated. Blockchain technology enables easy, auditable tracking of datasets generated by clinical researchers, benefitting government agencies tasked with approving drugs while producing better health outcomes for healthcare providers and patients. In 2021, I expect to see a rise in the use and uptake of applications that use public blockchain systems to incentivize greater honesty in clinical research.
Alex Lazarow, Investment Director, Cathay Innovation
The Future of US Healthcare is Transparent, Fair, Open and Consumer-Driven
In the last year, the pandemic put a spotlight on the major gaps in healthcare in the US, highlighting a broken system that is one of the most expensive and least distributed in the world. While we’ve already seen many boutique healthcare companies emerge to address issues around personalization, quality and convenience, the next few years will be focused on giving the power back to consumers, specifically with the rise of insurtechs, in fixing the transparency, affordability, and incentive issues that have plagued the private-based US healthcare system until now.
Lisa Romano, RN, Chief Nursing Officer, CipherHealth
Hospitals will need to counter the staff wellness fallout
The pandemic has placed unthinkable stress on frontline healthcare workers. Since it began, they’ve been working under conditions that are fundamentally more dangerous, with fewer resources, and in many cases under the heavy emotional burden of seeing several patients lose their battle with COVID-19. The fallout from that is already beginning – doctors and nurses are leaving the profession, or getting sick, or battling mental health struggles. Nursing programs are struggling to fill classes. As a new wave of the pandemic rolls across the country, that fallout will only increase. If they haven’t already, hospitals in 2021 will place new premiums upon staff wellness and staff health, tapping into the same type of outreach and purposeful rounding solutions they use to round on patients.
Kris Fitzgerald, CTO, NTT DATA Services
Quality metrics for health plans – like data that measures performance – was turned on its head in 2020 due to delayed procedures. In the coming year, we will see a lot of plans interpret these delayed procedures flexibly so they honor their plans without impacting providers. However, for so long, the payer’s use of data and the provider’s use of data has been disconnected. Moving forward the need for providers to have a more specific understanding of what drives the value and if the cost is reasonable for care from the payer perspective is paramount. Data will ensure that this collaboration will be enhanced and the concept of bundle payments and aligning incentives will be improved. As the data captured becomes even richer, it will help people plan and manage their care better. The addition of artificial intelligence (AI) to this data will also play a huge role in both dialog and negotiation when it comes to cost structure. This movement will lead to a spike in value-based care adoption
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COVID-19 was the dominant — but not the only — health policy story of 2020. In this special year-in-review episode of KHN’s “What the Health?” podcast, panelists look back at some of the biggest non-coronavirus stories. Those included Supreme Court cases on the Affordable Care Act, Medicaid work requirements and abortion, as well as a year-end surprise ending to the “surprise bill” saga.
This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Anna Edney of Bloomberg News and Sarah Karlin-Smith of Pink Sheet.
Among the takeaways from this week’s podcast:
- The coronavirus pandemic strengthened the hand of ACA supporters, even as the Trump administration sought to get the Supreme Court to overturn the federal health law. Many people felt it was an inopportune time to get rid of that safety valve while so many Americans were losing their jobs — and their health insurance — due to the economic chaos from the virus.
- Preliminary enrollment numbers released by federal officials last week suggest that more people were taking advantage of the option to buy coverage for 2021 through the ACA marketplaces than for 2020, even in the absence of enrollment encouragement from the federal government.
- The ACA’s Medicaid expansion had a bit of a roller-coaster ride this year. Voters in two more states — Oklahoma and Missouri — approved the expansion in ballot measures, but the Trump administration continued its support of state plans that require many adults to prove they are working in order to continue their coverage. The Supreme Court has agreed to hear a challenge to that policy. Although lower courts have ruled that the Medicaid law does not allow such restrictions, it’s not clear how the new conservative majority on the court will view this issue.
- Concerns are beginning to grow in Washington about the near-term prospect of the Medicare trust fund going insolvent. That can likely be fixed only with a remedy adopted by Congress, and that may not happen unless lawmakers feel a crisis is very near.
- The Trump administration has sought to bring down drug out-of-pocket expenses for Medicare beneficiaries. Among those initiatives is a demonstration project to lower the cost of insulin. About a third of Medicare beneficiaries will be enrolled in plans that offer reduced prices in 2021. But the effort could have a hidden consequence: higher insurance premiums.
- Many members of Congress began this session two years ago with grand promises of working to lower drug prices — but they never reached an agreement on how to do it.
- President Donald Trump, however, was strongly motivated by the issue and late this year issued an order to set many Medicare drug prices based on what is paid in other industrialized nations. Drugmakers detest the idea and have vowed to fight it in court. Although some Democrats endorse the concept, it seems unlikely that President-elect Joe Biden would want to spend much capital in a legal battle for a plan that hasn’t been carefully vetted.
- The gigantic spending and COVID relief bill that Congress finally approved Monday includes a provision to protect consumers from surprise medical bills when they are unknowingly treated by doctors or hospitals outside their insurance network. The law sets up a mediation process to resolve the charges, but the process favors the doctors. Insurers are likely to pass along any extra costs to consumers through higher premiums.
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A recent Advisory Board briefing examined the annual Centers for Medicare & Medicaid Services (CMS) Readmission penalties. Of the 3,080 hospitals CMS evaluated, 83% received a penalty for payments to be made in 2021, based on expected outcomes for a wide variety of treated conditions. While CMS indicated that some of these penalties might be waived or delayed due to the impacts of the Covid pandemic on hospital procedure volumes and revenue, they are indicative of a much larger issue.
For too long, patients discharged from the hospital have been handed a stack of papers to fill prescriptions, seek follow-up care, or take other steps in their journey from treatment to recovery. More recently, the patient is given access to an Electronic Health Record (EHR) portal to view their records, and a care coordinator may call in a few days to check-in. These are positive steps, but is it enough? Although some readmissions cannot be avoided due to unforeseen complications, many are due to missed follow-up visits, poor medication adherence, or inadequate post-discharge care.
Probably because communication with outside providers has never worked reliably, almost all hospitals have interpreted ‘care coordination’ to mean staffing a local team to help patients with a call center-style approach. Wouldn’t it be much better if the hospital could directly engage and enable the Primary Care Physician (PCP) to know the current issues and follow-up directly with their patient?
We believe there is still a real opportunity to hold the patient’s hand and do far more to guide them through to recovery while reducing the friction for the entire patient care team.
Strengthening Care Coordination for a Better Tomorrow
Coordinating and collaborating with primary care, outpatient clinics, mental health professionals, public health, or social services plays a crucial role in mitigating readmissions and other bumps along the road to recovery. Real care coordination requires three related communication capabilities:
1. Notification of the PCP or other physicians and caregivers when events such as ED visits or Hospitalization occur.
2. Easy, searchable, medical record sharing allows the PCP to learn important issues without wading through hundreds of administrative paperwork.
3. Secure Messaging allows both clinicians and office staff to ask the other providers questions, clarify issues, and simplify working together.
There are some significant hurdles to improve the flow of patient data, and industry efforts have long been underway to plug the gaps. EHR vendors, Health Information Exchanges (HIEs), and a myriad of vendors and collaboratives have attempted to tackle these issues. In the past few decades, government compliance efforts have helped drive medical record sharing through the Direct Messaging protocol and CCDAs through Meaningful Use/Promoting Interoperability requirements for “electronic referral loops.” Kudos to the CMS for recognizing that notifications need to improve from hospitals to primary care—this is the key driver behind the latest CMS Final Rule (CMS-9115-F) mandating Admission, Discharge, and Transfer (ADT) Event Notifications. (By March 2021, CMS Conditions of Participation (CoPs) will require most hospitals to make a “reasonable effort” to send electronic event notifications to “all” Primary Care Providers (PCPs) or their practice.)
However, to date, the real world falls far short of these ideals: for a host of technical and implementation reasons, the majority of PCPs still don’t receive digital medical records sent by hospitals, and the required notifications are either far too simple, provide no context or relevant encounter data, rarely include patient demographic and contact information, and almost never include a method for bi-directional communications or messaging.
Delivering What the Recipient Needs
PCPs want what doctors call the “bullet” about their patient’s recent hospitalization. They don’t want pages of minutia, much of it repetitively cut and pasted. They don’t want to scan through dozens or hundreds of pages looking for the important things. They don’t want “CYA” legalistic nonsense. Not to mention, they learn very little from information focused on patient education.
An outside practitioner typically doesn’t have access to the hospital EHR, and when they do, it can be too cumbersome or time-consuming to chase down the important details of a recent visit. But for many patients—especially those with serious health issues—the doctor needs the bullet: key items such as the current medication list, what changed, and why.
Let’s look at an example of a patient with Congestive Heart Failure (CHF), which is a condition assessed in the above-mentioned CMS Readmission penalties. For CHF, the “bullet” might include timely and relevant details such as:
– What triggered the decompensation? Was it a simple thing, such as a salty meal? Or missed medication?
– What was the cardiac Ejection Fraction?
– What were the last few BUN and Creatinine levels and the most recent weight?
– Was this left- or right-sided heart failure?
– What medications and doses were prescribed for the patient?
– Is she tending toward too dry or too wet?
– Has she been postural, dizzy, hypotensive?
Ideally, the PCP would receive a quick, readable page that includes the name of the treating physician at the hospital, as well as 3-4 sentences about key concerns and findings. Having the whole hospital record is not important for 90 percent of patients, but receiving the “bullet” and being able to quickly search or request the records for more details, would be ideal.
Similar issues hold true for administrative staff and care coordinators. No one should play “telephone tag” to get chart information, clarify which patients should be seen quickly, or find demographic information about a discharged patient so they can proactively contact them to schedule follow-up.
Building a Sustainable, Long-Term Solution
Having struggled mightily to build effective communications in the past is no excuse for the often simplistic and manual processes we consider care coordination today.
Let’s use innovative capabilities to get high-quality notifications and transitions of care to all PCPs, not continue with multi-step processes that yield empty, cryptic data. The clinician needs clinically dense, salient summaries of hospital care, with the ability to quickly get answers—as easy as a Google search—for the two or three most important questions, without waiting for a scheduled phone call with the hospitalist. X-Rays, Lab results, EKGs, and other tests should also be available for easy review, not just the report. After all, if the PCP needs to order a new chest x-ray or EKG how can they compare it with the last one if they don’t have access to it?
Clerical staff needs demographic information at their fingertips to “take the baton” and ensure quick and appropriate appointment scheduling. They need to be able to retrieve more information from the sender, ask questions, and never use a telephone. Additionally, both the doctor and the office staff should be able to fire off a short note and get an answer to anyone in the extended care team.
That is proper care coordination. And that is where we hope the industry is collectively headed in 2021.
About Peter Tippett MD, PhD: Founder and CEO, careMESH
Dr. Peter S. Tippett is a physician, scientist, business leader and technology entrepreneur with extensive risk management and health information technology expertise. One of his early startups created the first commercial antivirus product, Certus (which sold to Symantec and became Norton Antivirus). As a leader in the global information security industry (ICSA Labs, TruSecure, CyberTrust, Information Security Magazine), Tippett developed a range of foundational and widely accepted risk equations and models.
About Catherine Thomas: Co-Founder and VP, Customer Engagement, careMESH
Catherine Thomas is Co-Founder & VP of Customer Engagement for careMESH, and a seasoned marketing executive with extensive experience in healthcare, telecommunications and the Federal Government sectors. As co-founder of careMESH, she brings 20+ years in Strategic Marketing and Planning; Communications & Change Management; Analyst & Media Relations; Channel Strategy & Development; and Staff & Project Leadership.
With the public health emergency top of mind, it may be easy to forget that new federal technology requirements — electronic visit verification (EVV), in particular — are right around the corner.
Starting on Jan. 1 of next year, Medicaid-reimbursed home care providers are required to electronically verify the services that they deliver in the field. Caregivers must record data points, including date, time, location, type of service and other information.
Medicare-certified home health providers won’t have to do so until Jan. 1, 2023.
EVV originally became law in 2016 under the 21st Century Cures Act, with the goal of curbing fraud and abuse in the delivery of home-based care. The law sets the federal guidelines for EVV, but the mandate is administered at the state level.
States that aren’t compliant with EVV guidelines by the Jan. 1 deadline will be subject to a reduction in Federal Medical Assistance Percentage funding, which in turn impacts resources for state programs.
In some ways, it makes sense that the implementation of EVV has been placed on the backburner for some providers.
Originally, EVV adoption was supposed to take effect on Jan. 1 of 2020 — this year. Instead, most states — New York, for example — applied for and received exemptions, which pushed implementation back a year.
“New York state had several requests to postpone the implementation, given the difficulties in rolling this out in the personal care industry,” Emina Poricanin, managing attorney of New York-based Poricanin Law, told Home Health Care News. “Those were granted. New York state didn’t have the ability to just unilaterally postpone it.”
Now, roughly two weeks before providers are meant to be in compliance with the law, some providers feel less than prepared, according to Poricanin.
“There are way too many providers out there who are still calling to this day, asking what is EVV and what do I have to do about it,” she said. “Those are very late questions to be asking at this point in the game.”
States also have a hand in overall preparedness industry-wide, Courtney Martin, EVV expert of technology solutions provider CellTrak, told HHCN.
“That very much depends on the local state implementation plan. … Some states have been early with their implementation and are already to the point where they’ve given a lot of guidance to their providers around expectations and how they’ll be measured against them,” Martin said. “About half the states have done that. Then there are some states that are taking a little bit longer to implement.”
CellTrak is a Schaumburg, Illinois-based provider of home-based care solutions, including EVV, for more than 4,000 home care agencies internationally.
Providers have two responsibilities when it comes to the mandate. They have to collect correct, compliant EVV information in the field, at the point of care. Additionally, providers have to relay that information to the state or to the managed care organization that requires this data for compliance.
This means that whatever technology solutions a provider has in place must help them accomplish this, according to Martin.
To this end, providers have the option of implementing either a state-procured EVV solution or a commercially available solution.
“Those decisions are obviously very unique to the providers,” Martin said. “Generally speaking, the state system will include a very straightforward check the box compliance. Some providers that are trying to meet the minimum requirement, may choose to adopt the free solution.”
However, for providers that operate on a multi-state level, this may create challenges, according to Martin.
“The downside to a free solution is that if you are operating in multiple states, and those states all have different free solutions, this can be complicated for an agency,” she said. “Now, the agency is trying to support training and monitoring their caregivers on these different state solutions.”
When it comes to deciding on a technology solution, providers should consider their company’s operational workflow, as well as state compliance requirements.
As the EVV implementation date inches closer, Martin stressed the importance of providers beginning the data collection and documentation process as soon as possible.
“We encourage providers to do that, rather than waiting for state guidance,” she said. “The reason being that it’s time for their caregivers to get used to the technology solution. It gives them time to think through how their workflow, internal to the agency, is after their EVV processes are in place. It also gives them time to be prepared for when that state guidance comes.”
Providers should also follow state stakeholder meetings in order to stay up to date with the new information.
The state of New York, for example, has held weekly calls over the past several months. The aim of the calls was to help providers get prepared and address some of the technical issues associated with EVV, according to Poricanin.
As providers continue to operate amid the public health emergency, Martin believes that EVV adoption will help improve care delivery.
“You’re going to have way more information about that patient — and about the care that they need,” she said. “This can help you do a better job in the visit and also alert you to any specific circumstances that you need to know, including that patient’s potential sensitivity to being exposed to COVID-19.”
The post Providers Scramble to Figure Out EVV as Implementation Date Inches Closer appeared first on Home Health Care News.
A global health crisis has thrust us into a scenario in which lives quite literally depend on the ability to virtually connect. Telehealth has rapidly emerged as a vital tool, enabling continuity of care, allowing vulnerable individuals to access their physician from home, and freeing up resources for providers to treat the most critical patients. The acceptance of telehealth and expansion of covered services for the senior population demonstrate that this technology will endure long after COVID-19 subsides.
Prior to the pandemic, just 11% of Americans utilized telehealth compared to 46% so far this year, and virtual healthcare interactions are expected to top 1 billion by year’s end. While the technology has been a life-saver for many, usage depends heavily on the availability of audio-video capabilities, internet access, and technological prowess – potentially leaving vulnerable patients behind.
Seniors Face Physical, Technical and Socioeconomic Barriers to Telehealth
Despite telehealth’s surge, there is growing concern that the rapid shift to digitally delivered care is leaving seniors behind. Telehealth is not inherently accessible for all and with many practices transitioning appointments online, it threatens to cut older adults off from receiving crucial medical care. This is a significant concern, considering older adults account for one-quarter of physician office visits in the United States and often manage multiple conditions and medications, and have a higher rate of disability. This puts an already vulnerable population at a higher risk of severe complications from COVID-19.
Research published recently in JAMA Internal Medicine found that more than a third of adults over age 65 face potential difficulties accessing their doctor through telehealth. Obstacles include familiarity using mobile devices, troubleshooting technical issues that arise, managing hearing or vision impairments, and dealing with cognitive issues like dementia. Many of these difficulties stem from the natural aging process; it is imperative for provider organizations employing telehealth and telehealth vendors to improve offerings that consider vision, hearing, and speaking loss for this population.
While barriers associated with aging are a key factor within the senior population, perhaps the greatest challenges in accessing telehealth are socioeconomic. The rapid shift to digital delivery of care may have left marginalized populations without access to the technological tools needed to access care digitally, such as high-speed internet, a smartphone or a computer.
According to the JAMA study, low-income individuals living in remote or rural locations faced the greatest challenges in accessing telehealth. A second JAMA study, also released this summer indicated that “the proportion of Medicare beneficiaries with digital access was lower among those who were 85 or older, were widowed, had a high school education or less, were Black or Hispanic, received Medicaid, or had a disability.”
These socioeconomic factors are systemic issues that existed prior to the pandemic, and the crisis-driven acceleration of telehealth has magnified these pre-existing challenges and widened racial and class-based disparities. Recent initiatives at the federal level, such as the FCC’s rural telehealth expansion task force, are a step in the right direction, though more sustained action is needed to address additional socioeconomic challenges that are deeply rooted within the healthcare system.
Fortunately, Telehealth Hurdles Can Be Overcome
Recognizing that telehealth isn’t a “one-size fits all” solution is the first step towards addressing the barriers that disproportionately impact seniors and work is needed on multiple levels. Telemedicine consults are impossible without access to the internet, so the first step is to provide and expand access to broadband and internet-connected devices. With more than 15% of the country’s population living in rural areas, expanding broadband access for these individuals is especially crucial. In addition, older adults in community-based living environments need greater access to public wi-fi networks.
Access to mobile and other internet-connected devices is also essential. Products designed with large fonts and icons, closed captioning, and easy set-up procedures may be easier for older adults to use. For example, GrandPad is a tablet designed specifically for seniors and has an intuitive interface that includes basic video calling, enabling seniors to virtually connect with their caregivers.
To address affordability, the Centers for Medicaid and Medicare Services (CMS) allowed for mid-year benefit changes in 2020 to allow for payment or provision of mobile devices for telehealth. Many Medicare Advantage organizations are enhancing plans’ provisions of telehealth coverage and devices for 2021.
In addition to increasing access to broadband and internet-connected devices, providing seniors with proper educational resources is another crucial step. Even if older adults are open to using technology for telehealth visits, many will need additional training. Healthcare organizations may want to connect older patients with community-based technology training programs. Some programs take a multi-generational approach, pairing younger instructors with older students.
For example, Papa is an on-demand service that pairs older adults with younger ‘Papa Pals’ who provide companionship and assistance with tasks such as setting up a new smartphone or tablet.
From a socioeconomic perspective, careful consideration is needed to address the concerns that telehealth may reinforce systemic biases and widen health disparities. Providers may be less conscious of systemic bias toward patients based on race, ethnicity, or educational status.
In turn, providers must address implicit bias head-on, such as offering workplace training and incorporating evidence-based tools to adequately measure and address health disparities. This includes pushing for policies that enable widespread broadband access funding to better connect communities in need.
Health plans can support expanded access to care through benefit design, reducing costs for plan members. To match members and patients with the right resources and assistance, health plans and providers should launch outreach campaigns that are segmented by demographic group. Outreach initiatives could include assessments to determine each person’s ability and comfort level with telehealth.
The Path Forward
Without question, telehealth is playing a central role in delivering care during the current pandemic, and many of its long-touted benefits have been accentuated by the current demand. Telehealth, along with other digital monitoring technologies, have the potential to address several barriers to care for seniors and other vulnerable populations for whom access to in-person care may not be viable, such as those based in remote locations or with mobility issues.
In the post-pandemic era, telehealth can provide greater access and convenience, but if not implemented carefully, the permanent expansion of telehealth may worsen health disparities. Careful consideration and collaboration will be essential in embracing the value of telehealth while mitigating its inherent risks.
If implemented correctly, telehealth can provide continued access to care for our vulnerable aging population and can significantly improve care as well. Enhancing the ability to connect with healthcare providers anytime, anywhere can give seniors the freedom to gracefully age in place.
About Anne Davis
Anne Davis is the Director of Quality Programs & Medicare Strategy at HMS, a healthcare technology, analytics, and engagement solutions company, where she’s focused on the company’s Population Health Management product portfolio.
When 2020 began, no one anticipated that complying with the Merit-based Incentive Payment System (MIPS)—the flagship payment model of the Centers for Medicare & Medicaid Services (CMS) Quality Payment Program (QPP)—would look so different halfway through the year. Like many other things, the COVID-19 crisis has delayed, diverted, or derailed many organizations’ reporting efforts and capabilities. Lower procedure volumes, new remote work scenarios, and shifting priorities have taken attention away from MIPS work.
Despite the disruptions and uncertainties associated with the pandemic, healthcare organizations should not lose track of MIPS compliance and the program’s intent to improve care quality, reduce costs, and facilitate interoperability. Here are a few strategies for keeping a MIPS program top of mind.
Understand the immediate effects of the pandemic on MIPS reporting
Due to COVID-19, CMS granted several 2019 data reporting exceptions and extensions to clinicians and providers participating in Medicare quality reporting programs. These concessions were enacted to let providers focus 100% of their resources on caring for and ensuring the health and safety of patients and staff during the early weeks of the crisis. For the 2020 MIPS performance period, CMS has also chosen to use the Extreme and Uncontrollable Circumstances policy to allow requests to reweight any or all of the MIPS performance categories to 0%.
Clinicians and groups can complete the application any time before the end of this performance year. If practices are granted reweighting one or more categories but submit data during the attestation period, the reweighting will be void and the practice will receive the score earned in the categories for which they submit data
Seize the opportunity to improve interoperability
Interoperability is a key area that organizations were focused on before the crisis, and this work still warrants attention. If an organization is not on the front lines of the COVID-19 response, it should use this time to shore up communications with other entities so, once things return to “normal,” it will be well prepared to seamlessly exchange information with peer organizations.
Establishing processes for sending and receiving care summaries via direct messaging is important for practices to earn a high score in the Promoting Interoperability category. Direct messaging is a HIPAA-compliant method for securely exchanging health information between providers, which functions as an email but is much more secure due to encryption. A regular pain point organizations face is being unable to obtain direct messaging addresses from peer organizations, including referral partners.
To assist providers in this area, the Office of the National Coordinator for Health Information Technology (ONC) and CMS has created a mandatory centralized directory of provider electronic data exchange addresses published by the National Plan & Provider Enumeration System (NPPES). The NPPES directory is searchable through a public API and allows providers to look up the direct messaging addresses for other providers. To meet current interoperability requirements, providers must have entered their direct messaging address into the system by June 30, 2020. If they haven’t done so, the provider could be publicly reported for failure to comply with the requirement, which could constitute information blocking.
Take time now to ensure direct messaging addresses have been entered correctly for all members of your practice. This is also a good time to begin reaching out to top referral sources to make sure they are also prepared to send and receive information.
Look for ways to streamline quality reporting
Over the next few months, the focus will return to quality measure reporting. As such, it’s wise to take advantage of this time to ensure solid documentation and reporting methods. Electronic medical records (EMRs) can be helpful in streamlining these efforts.
For example, dropdown menus with frequently used descriptions and automated coding can enable greater accuracy and specificity while easing the documentation process for providers. Customizable screens that can be configured to include specialty-specific choices based on patient history and problem list can also smooth documentation and coding, especially if screen layouts mirror favored workflow.
Regarding MIPS compliance in particular, it can be helpful to use tools that offer predictive charting. This feature determines whether a patient qualifies for preselected MIPS measures in real-time and presents the provider with data fields related to those items during the patient encounter—allowing the physician to collect the appropriate information without adding additional charting time later on.
With respect to reporting, providers may benefit from using their certified EMR in addition to reporting through a registry. At the beginning of the MIPS program, providers could report through both a registry and EMR directly and would be scored separately for their quality category through each method. They would then be awarded the higher score of the two. This method had the potential to leave some high-scoring measures on the table.
Beginning in 2019, providers reporting through both registry and EMR direct are scored across the two methods. CMS uses the six highest scoring measures between the two reporting sets to calculate the provider’s or group’s quality score, potentially resulting in a higher score than the provider would earn by reporting through either method alone.
A knowledgeable partner can pave the way to better performance
COVID-19 has impacted healthcare like no other event in recent history, and it’s not surprising that MIPS compliance has taken a back seat to more pressing concerns. However, providers still have the opportunity to make meaningful progress in this area. By working with a technology partner that keeps up with the current requirements and offers strategies and solutions for optimizing data collection and reporting, a provider can realize solid MIPS performance during and beyond this unprecedented time.
About Courtney Tesvich, VP of Regulatory at Nextech
Courtney is a Registered Nurse with more than 20 years in the healthcare field, 15 of which have been focused on quality improvements and regulatory compliance. As VP of Regulatory at Nextech, Courtney is responsible for ensuring that Nextech’s products meet government certification requirements and client needs related to the regulatory environment.
What You Should Know:
– Cityblock Health, a transformative, value-based healthcare provider focused on improving healthcare outcomes for marginalized communities, today announced a $160M Series C round, bringing its total raised to $300M.
– Cityblock is a care delivery trailblazer working to right the injustices of a healthcare system that cycles vulnerable communities through frequent ER visits and hospital stays. Its tech-enabled model delivers primary care, behavioral care, and social services, virtually and in-person, to the Medicaid and lower-income Medicare beneficiary communities.
– Cityblock provides social services that address core
aspects of poverty in order to improve health outcomes, including access to
nutritious food and support to safely care for oneself.
Health, a Brooklyn, NY-based healthcare provider for lower-income
communities, announced today the completion of a $160 million Series C funding
round and a valuation of over $1 billion. New Cityblock investor General Catalyst
led the round, with participation from crossover investor Wellington Management
and support from major existing investors, including Kinnevik AB, Maverick
Ventures, Thrive Capital, Redpoint Ventures, and more. The investment round
brings Cityblock’s total equity funding to $300 million, as they look to grow
their footprint to democratize access to community-based integrated care in a
more than $1.3 trillion market.
Care That Meets You Where You Are
Spun out of Sidewalk Labs, an Alphabet Company in 2017 and anchored in a first partnership with EmblemHealth, Cityblock is a transformative, value-based healthcare provider focused on improving outcomes for Medicaid and lower-income Medicare beneficiaries. The company provides medical care (both primary care and complex specialty services), behavioral health, and social services to its members virtually, in their homes, in the community, and in its neighborhood hubs. Their model reflects an underlying philosophy that improving health outcomes and minimizing systemic healthcare inequities requires fundamentals that address the root effects of poverty, like having access to nutritious food or the ability to safely care for yourself and others.
Value-Based Care Model
Cityblock leverages a value-based model, instead of a
fee-for-service basis, like most healthcare providers. Cityblock splits the
cost savings that come from better outcomes with the healthcare payer. Cityblock’s
financial structure squarely aligns the health needs of its members to continuously
deliver patient-centric care.
Cityblock is powered by Commons a groundbreaking care delivery platform that brings together distributed community-based care teams, care delivery workflows, data feeds, and multimodal member interactions. It allows social workers, pharmacists, doctors, paramedics, and our virtual care teams to all come together on the same page in real-time. With each new market we enter, our technology reinforces our care model, allowing us to serve more members while ensuring consistently high quality, empathetic, and effective care.
Integrated Care Team
Cityblock’s integrated care teams include doctors, nurses,
advanced practice clinicians, behavioral health specialists, licensed clinical
social workers, and community health partners, and leverage close partnerships
with existing healthcare providers and community-based social services
Today, Cityblock provides care to 70,000 members in Connecticut,
New York, Massachusetts, and Washington D.C., with high member engagement and
NPS scores of high 80s to 90s across its markets. Over the past year, Cityblock
members have seen reductions in in-patient hospital admission rates and
improvements in quality outcomes, keeping people healthier and driving down
costs across the board, while more than doubling membership and revenue,
The Impact of COVID Has Magnified Health Disparities
According to Cityblock, the COVID-19 pandemic has
significantly magnified health disparities highlighting three fundamental
– Inequity of
America’s social infrastructure, including the legacy of systemic racism, has
created unacceptably disparate health outcomes
– Healthcare’s volume-based, fee-for-service payment model contributes
poor outcomes, especially for marginalized communities
– The models that
have to-date addressed key components of these challenges have not successfully
Story of Cityblock Member Sonia
The story of Sonia, a Cityblock member, is featured in the blog post announcing the raise. Counted out and considered
a ‘nuisance’ by the healthcare system, Sonia was visiting the emergency room
several times a week for care and services, resulting in poor outcomes for the
health system and for herself. Cityblock enrolled Sonia in their high-risk
short-term housing program, placing her into a hotel during the peak of her
community’s Covid-19’s outbreak. As her trust in Cityblock grew, Sonia worked
with Cityblock and its community partners to secure permanent housing. Over the
course of two years, Sonia saw a 21% reduction in hospital use and a 24%
reduction in monthly costs, and has had zero ER visits since April 2020.
“The devastating impact of COVID-19 has been a painful
reminder of the vulnerability of lower-income communities and communities of
color,” said Iyah Romm, Cityblock Health co-founder and CEO. “We cannot turn a
blind eye to a healthcare system that cycles vulnerable communities through
frequent ER visits and hospital stays. We believe that new models of care
delivery, rooted in preventative care and augmented with social services, are
one major path forward to righting the injustices of our healthcare system.
This starts with listening to our members, extends through changing payment
models to create sustainability for primary care providers and building
technology to democratize access to the care models that we are building.”
What You Should Know:
– Elation Health, which provides an easy-to-use and
affordable clinical technology platform for more than 7 million independent primary
care clinicians serving 14M+ patients – including an EHR raises $40M in Series
C funding from Al Gore’s sustainable investment firm, Generation Investment
– Elation’s API-enabled platform also allows
organizations to transform the patient and provider experience and implement
their own models of data-driven, value-based care.
– Company will surpass a milestone this year of
delivering more than 20 million in-office and virtual visits through their
Health, a clinical-first technology company powering the future of
independent primary care, today announced a Series C financing round of $40
million led by Al Gore’s Generation Investment
Management, a firm that invests in sustainable businesses accelerating the
transition to a more healthy, fair, safe, and low-carbon society. The round
also included participation from existing investors, including Threshold Ventures and Kapor Capital.
Clinical-First Commitment to Independent Primary Care
Independent primary care is one of the few areas in healthcare where upfront investment leads to significant savings in the long term. For every dollar spent on primary care, studies suggest that as much as $13 in downstream healthcare costs are avoided. Increased spending on primary care is also associated with fewer emergency department visits and reduced total hospitalizations and specialty interventions for chronic conditions such as diabetes, high blood pressure, and congestive heart failure
Elation Health was founded in 2010 after siblings Kyna and
Conan Fong struggled to help their father transition his solo primary care
practice from paper charts to a digital system. Born from that experience,
today Elation Health powers the largest network for independent primary care,
with 14,000 independent clinicians caring for seven million patients. The
company offers an EHR
solution, enterprise APIs, revenue cycle services, patient engagement app, and
access to interoperability partners.
The company surpassed a milestone this year of delivering more than 20 million in-office and virtual visits through its provider network. In addition to serving small practices, Elation has partnered with primary care innovators such as Crossover Health and Cityblock Health to provide the underlying clinical platform for technology-enabled, team-based care.
Helping Intendent Practices Shift to Virtual Care Amid The
In 2020, Elation Health’s customer base of independent
practices has faced significant business challenges as primary care shifts to
virtual settings and the pace of insurance and government policy change has
accelerated. The company has responded by expanding its role as a critical
technology partner — including adding HIPAA-compliant telehealth to its core
offering, deepening support for Medicare and Medicaid quality programs, and
delivering new patient engagement capabilities for patients to schedule
appointments and interact with practices. Elation’s API-enabled platform also
allows organizations to transform the patient and provider experience and
implement their own models of data-driven, value-based care.
In the year ahead, Elation Health will continue to invest in
its core platform, while adding new capabilities to support business operations
for independent primary care. The company has plans to develop solutions in
billing and payment collection, patient population management, interoperability,
and quality reporting — ensuring practices have the tools to drive high-quality
patient outcomes and business success.
A proposed rule would require HHS to analyze within 24 months about 2,400 regulations — rules that affect tens of millions of Americans on everything from Medicare benefits to prescription drug approvals.
The move has met a fierce backlash from health providers and consumer advocates who fear it would hamstring federal health officials while they seek to control the COVID-19 pandemic, which has killed more than 250,000 Americans.
The HHS proposal appears designed to tie up the incoming Biden administration, say critics. They note the timing of the proposal, which was issued Nov. 4 — the day after Election Day, when it appeared President Donald Trump would likely lose his bid for a second term.
“The cynical part of me thinks this is a perfectly designed way to bring the department to a standstill in the next administration,” said Mary Nelle Trefz, health policy associate at Common Good Iowa, a consumer advocacy group.
She said HHS does not have the bandwidth to review all these regulations during the next two years while running its many programs, including Medicaid and Medicare.
If the proposal is finalized before Jan. 20, it is likely to be undone by the incoming Biden administration. But the chore would add to duties of HHS officials trying to attack the pandemic, she said.
HHS officials deny their proposal was aimed at the Biden administration. Brian Harrison, chief of staff at the department, said he first sought legal review of the proposal in April. “Our lawyers moved as fast as they could,” he said, and the rule was written with the expectation it would be implemented during Trump’s second term.
“The outcome of the election had nothing to do with it,” he said.
Democrats and Republicans for the past 40 years have failed to review existing regulations, leaving unnecessary and irrelevant rules on the books, Harrison said.
But Andy Schneider, a research professor at the Center for Children and Families at Georgetown University who has written about the proposal, said he fears the sunset provision will be one of many actions the Trump team will take to distract the incoming administration.
“It speaks volumes that they waited until the end of the fourth year of the administration to decide that the regulatory process needs to be improved,” he said.
Incoming administrations have typically frozen new rules that were pending but have not taken effect before Inauguration Day. That gives new administrations time to unwind them.
Efforts to enact reviews of funding bills and other legislation, known as sunset clauses, have been popular among conservatives for years. The federal government has occasionally used sunset provisions in legislation, such as the tax cuts enacted during the George W. Bush administration, but it is rare to make department regulations subject to these types of mandatory deadlines.
The option is more popular among states, which have adopted varying procedures for measures passed by the legislatures or regulatory boards. Those efforts run the gamut from requiring most initiatives to be reviewed to identifying specific agencies or legislation that must be reconsidered on a regular timetable.
HHS accepted public comments on the proposal though Dec. 4, except on part of the rule affecting Medicare regulations, which has a Jan. 4 deadline. A final rule is expected before Biden becomes president on Jan. 20.
HHS officials don’t point to any specific regulations they say are outdated. However, in their supporting material for the proposal, they note in part:
“An artificial-intelligence-driven data analysis of HHS regulations found that 85 percent of department regulations created before 1990 have not been edited; the Department has nearly 300 broken citation references in the Code of Federal Regulations, meaning CFR sections that reference other CFR sections that no longer exist.”
Harrison said the scarcity of reviews is due to “inertia” and “lack of an incentive mechanism.”
“Many presidents have formally ordered their agencies to review existing regulations, and it has been existing law for 40 years, so simply asking the divisions to review these regulations has been tried for decades and proven to be ineffective,” Harrison said.
“We need to incentivize their behaviors,” he said.
With more than 80,000 employees, the department should be able to complete the review of 2,400 rules in 24 months, he added.
Harrison said the proposal is authorized by a law signed by President Jimmy Carter in the late 1970s requiring federal agencies to review existing rules. But that law has no provision that calls for cutting regulations that are not reviewed within a certain time frame, Schneider said.
The proposal says the HHS secretary would have flexibility to stop some regulations from being eliminated “on a case by case basis.”
HHS estimates the reviews would cost up to $19 million over two years. Regulations would have to be reviewed every 10 years under the proposal.
When he took office in 2017, Trump vowed that for every regulation his administration issued, it would remove two. In July, he said his administration had more than exceeded that goal.
“For every one new regulation added, nearly eight federal regulations have been terminated,” he said in a Rose Garden speech. The Washington Post Fact Checker said that claim was based on “dubious math and values each regulation as having equal weight.”
One of the few groups to endorse the HHS proposal is the National Federation of Independent Business. The group said the proposal would alleviate regulatory burdens on small businesses.
But other groups, such as the American Academy of Neurology, suggest the proposed rule would limit input from interest groups on changes to existing regulations, because it would not follow the usual process of seeking public comments when altering rules. “The AAN is highly supportive of the current process to modify and rescind regulations through the notice and comment period, as it affords stakeholders the necessary opportunity to provide feedback on proposed regulations prior to changes being implemented,” the group told HHS.
The Medicaid and CHIP Payment and Access Commission, which advises Congress, opposes the proposal. “MACPAC questions the need for a proposed rule that creates a duplicative and administratively burdensome new process that is likely to create confusion for beneficiaries, states, providers, and managed care plans,” the group said in a letter to HHS. “The new requirements will create additional unnecessary work that will distract the department and CMS from the critical roles they play in our health care system, Medicaid and CHIP amid the pandemic and its resulting economic challenges.”
It’s unclear how the proposed rule would affect long-standing regulations for product safety and standards, said Betsy Booren, senior vice president of the food lobbying group Consumer Brands Association. “The idea that these regulations would be sunset because a regulations timer went too long is not acceptable,” she wrote in comments on the proposed rule.
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What You Should Know:
– San Francisco-based digital health startup Pair Team
emerges out of stealth with $2.7M in seed funding backed by Kleiner Perkins,
Craft Ventures, & YC.
– Pair Team provides both a remote team and AI that automates workflows, provides infrastructure & improves medical practices — efficiencies and billing as you’d expect, but all driving toward value-based, quality patient care.
– Pair’s wrap-around technology tripled the rate of annual wellness visits and increased revenue by 15% for clinics in 2020.
Pair Team (“Pair”) announced today it has
emerged out of stealth and has raised $2.7 million in seed funding backed by Kleiner Perkins, Craft Ventures, and YCombinator, along with other prominent
funds. Pair is an end-to-end operations platform for value-based primary care,
backed by Pair’s own care team. For patients, Pair provides a digital front door
and helps them navigate healthcare.
Automate Primary Care Operations Infrastructure
Founded in 2019 by Neil Batlivala and Cassie Choi, RN after experiencing how critical a high functioning administrative team is to provide high-quality primary care by building out operations together at leading tech-enabled practices of Forward and Circle Medical. The majority of healthcare is local and fragmented, and no solutions were built to enable existing clinics. Pair came out of that need and provides a simple yet comprehensive solution that covers the front, mid, and back-office. Their automation, along with a human-in-the-loop approach provides end-to-end operations of patient outreach, scheduling, e-forms, care gap reports, record requests, referrals, lab coordination, etc., to offload the traditional job functions of the front desk and medical assistants.
“Primary care is systematically and chronically under-resourced. Pair ensures patients receive the very best practices in health care — from annual checkups, follow-ups after hospital discharge, and preventative care screenings,” commented Neil Batlivala, CEO and co-founder of Pair Team. “We not only monitor patient data, but we go further to operationalize it with automation and our care team.”
Pair provides a revenue-sharing model to the share cost of operations with primary care providers. The platform monitors health plan and system data to trigger automated workflows that engage patients to schedule clinically impactful visits, surface care recommendations to clinicians, and manage follow-up care coordination. Their bolt-on model allows them to work as an extension of your care team within existing processes and accelerate quality programs in days, not months. For practices, this drastically improves care quality and visit efficiency. For plans, this aligns day-to-day operations with a total cost of care.
Helping Medicaid Populations Navigate Their Healthcare
Medicaid and Medicare is struggling in an unprecedented way during COVID — many workers are losing access to healthcare through their employer and COVID job loss. During the first week of open enrollment, last month nearly 820,000 people selected plans on HealthCare.gov 2020, according to the Centers for Medicare & Medicaid Services (CMS). Federal Medicaid outlays increased more rapidly through 2nd half FFY 2020, up 22.5% as compared to prior year at 8.7% growth. So the number of patients coming onto the system is at unprecedented levels.
Pair helps Medicaid populations navigate their healthcare with follow-ups, preventive cancer screening, and those recommendations on current (and ever-changing) Medicaid requirements. The company starts with existing processes and accelerates quality programs in days, not months.
Despite COVID and patient’s avoidance of medical offices and care, Pair’s wrap-around operations technology and care team tripled the rate of preventative care visits and are on track to increase clinical revenue by 15% by end of the year through quality incentives alone. To date, Pair manages care for thousands of Medicaid patients in southern California and has closed hundreds of care gaps with their remote care team.
Telehealth and virtual care are not brand-new phenomena suddenly cobbled together as a rapid response to the onset of the COVID-19 pandemic, but the average US patient could be forgiven for thinking that it is. Indeed, virtual visits to care providers and remote patient monitoring have been available for quite some time, delivering two key benefits:
– Providing a platform to address cost-efficiencies and accessibility to quality healthcare for the populace at large
– Playing a key role in managing a growing population of chronically ill seniors.
Prior to 2020, however, the rules of reimbursement and implementation for associated telehealth services were difficult to navigate, wildly differing at the state and federal level with a host of regulations further complicating matters. Federal reimbursement policies are centered on Medicare, via the Centers for Medicare and Medicaid Services (CMS) – the single largest payer for seniors and chronically ill patients. Additionally, compliance with the Health Insurance Portability and Accountability Act (HIPAA) dictated rigorous standards for direct and monitoring communications between care providers and patients. Complicating matters further, US states offered a patchwork of individual telehealth laws dictating separate Medicaid policies.
The result was a lack of clarity of how healthcare providers could overcome regulatory and financial reimbursement barriers to implement effective telehealth programs as well as a lack of parity in coverage services and payments for patients. To address this at the federal level, CMS released new guidance in 2020 to relax reimbursement restrictions for providers. Now, we’re at the cusp of a new era of telemedicine where providers could widely offer:
– Virtual office visits that address traditionally in-person services such as primary care, behavioral health, and specialty care (e.g. pulmonary or cardiac health rehabilitation)
– On-demand virtual urgent care to address pressing concerns and urgently needed consultations
– Virtual broader home health services such as remote patient monitoring, outpatient disease management, and various forms of therapy (e.g. physical, speech)
– Tech-enabled home medication administration helping patients receive injectable or consumable medication via monitored self-administration
This is all, of course, dependent upon the mobile technology (e.g. tablets, wearables, etc.) and associated services that telehealth providers will rely upon to make these services happen at parity and scale for their patients. Even more importantly, virtual care programs being scaled up to cover a larger percentage of patients will fall apart if providers don’t have the resources to offer robust support and maintenance options for these devices and services. Quality of virtual care is highly dependent on persistent device and service availability and dependability.
Whether providers have already begun purchasing the mobile devices needed or are still struggling with the choice of what devices and services they need and/or can afford, however, they now face a different quandary: How to stand up these virtual care services at scale in a sustainable way that works within current budget resources and doesn’t pass on ballooning costs to your patients?
One way to make complex mobile technology deployments financially manageable is opting for a mobile device as a service (mDaaS) model which allows you to shift from a CapEx-based spending model to an OpEx spending model for purchasing hardware and allows telehealth providers to bundle or roll up a range of devices, accessories, services, maintenance and support into a single, predictable monthly per-device price. With mobile device technology rapidly evolving, telemedicine providers will need the operational agility to pivot to different solutions and quick technology refreshes as the need arises.
When done with the right third-party partner, it offers the additional advantages of outsourcing end-to-end support and lifecycle management to highly trained agents, who can free up precious IT resources. Most importantly, it creates a level of control over technology and spend that makes standing up virtual care programs convenient and stress-free.
There are many options to consider when expanding telemedicine services rapidly to larger patient bases, whether during disruptive events such as the COVID-19 pandemic or in the years to come. The key to making these services sustainable is finding a financing model that will free up internal resources, offer greater spending flexibility, and offer end-to-end support for your healthcare mobile technology ecosystem.
About Don Godbee Senior Mobile Solutions Architect at Stratix
Don brings a unique perspective to mobility in the Healthcare Vertical with over 25 years of consulting and delivery of critical solutions. Don has delivered various solutions from OEM integration of sensors in medical devices to mobile point of care solutions and services with major EHR software solution providers such as Epic, Cerner, GE Healthcare, Allscripts, and McKesson.
As if 2020 couldn’t be
any more challenging for healthcare providers, new federal rules on
interoperability and patient access, granting patients direct access to their healthcare
data, begin taking effect this November and continue into 2022. These rules,
while ultimately beneficial to patients, bring an additional level of
operational complexity to many revenue-stressed healthcare organizations.
If anything, the 2020 pandemic has illustrated the vast potential of interoperability. For example, consider the huge increase in 2020 in virtual care visits, projected to be more than 1 billion by year’s end, and with an estimated 90% related to Covid-19. Many of these new virtual health patients will move through different care networks, using different health plans, and seeking remote access to their health records. These are precisely the type of patients’ interoperability is meant to help.
What should healthcare providers be doing now to ensure they’re not only compliant with new interoperability rules, but also applying them as optimally as possible to benefit their patients and organizations? In this article, we review the upcoming rules and suggest five key steps providers can take to ensure their interoperability implementations proceed as smoothly as possible.
What’s Ahead with
After several years of discussion on interoperability standards, the Office of the National Coordinator (ONC) for Healthcare IT and the Centers for Medicare & Medicaid Services (CMS) issued their final rules on interoperability in the spring of 2020. The new rules, covering both health systems and health plans, are intended to ensure that patients can electronically access their healthcare information regardless of health system or type of electronic health records (EHR) and covering all CMS-regulated plan types, including Medicare Advantage, CHIP, and the Federally Facilitated Exchanges.
Starting Nov. 2, 2020, healthcare systems must begin complying with interoperability rules preventing information blocking, which means not interfering with patients’ access to or use of their electronic health information. Providers must also attest they are acting “in good faith” regarding preventing information blocking, with any non-compliance flagged on the National Plan and Provider Enumeration System. By May 1, 2021, hospitals, psychiatric hospitals, and critical access hospitals with an EHR must send notification of their patients’ admission, discharge, and transfer (ADT) events to providers.
Interoperability will replace the current fragmented and error-prone ways of exchanging vital healthcare information. Near-term benefits of interoperability include improved care coordination and patient experience, greater patient safety, and stronger patient privacy and security. Longer-term benefits include higher provider productivity, reduced healthcare costs, and more accurate public health data.
For providers, the good
news about interoperability is that they’ve had years to think about and
implement many of its fundamental tenets, based on their work meeting
meaningful use requirements. That’s borne out in a 2019 HIMSS survey of
healthcare organizations which found nearly 75% of respondents past the
“foundational” level of interoperability – “foundational” defined as allowing
data exchange from one IT
system to another, but without data interpretation.
Five Steps for
While healthcare systems
will achieve significant interoperability gains through technology investments,
they should not consider technology as the ultimate sole key to
interoperability success. If anything, financial and political considerations
may be far more important to your organization’s interoperability success. Here
are five critical non-technology factors to consider:
1. Determine your “master”
All pertinent stakeholders in your organization should be on the same page about your interoperability strategy, resources, and timing. Know up-front that those implementing interoperability may not have previously worked with patient-centric analytics, partners, or departments in your organization. Plan your resources and timing accordingly. Your strategy should focus on the value-add of interoperability internally, such as access to additional data points on your patients, and externally, such as how you describe the upcoming benefits of interoperability to your patients.
2. Convey your vision, expectations
and expected return
An interoperability implementation is
a massive change management initiative, which requires continuous, top-down
leadership and championship, and proper expectation-setting. Communicate where
your organization currently stands regarding its interoperability capabilities,
and where you wish to have it go. Convey how the organization plans to get to
its future desired state. And perhaps most importantly, share the likely return
on investment in this effort. Be as specific as possible. For example, if you
believe interoperability gains will ultimately enable a 5% decrease in your
hospital readmissions, state that.
3. Examine workflows and identify
specific use cases
Every type of ADT event in your
organization, and its corresponding workflows and system interactions, should
be under review. Consider all types of clinical use cases, the types of data to
be exchanged, and those involved in providing patient care. This will help
determine your optimal approach to data-sharing and how your organization can
strategically use the additional data you receive from other health
4. Rigorously prep your data
Standardized data collection and reporting
which produces quality data is the heart and soul of successful
interoperability. Be sure your organization’s data is clean and meaningful, and
will ultimately be understandable and useful to your patients.
5. Think big-picture differentiation
There’s nothing in the ONC and CMS
interoperability rules that says you need to stop at mere rules compliance.
Consider your pursuit of interoperability as a singular opportunity to be a
patient-centric leader in your market. Let everyone relevant know of the
success you’ve achieved.
offers a chance for healthcare systems to achieve multiple operational gains,
when handled well, it is ultimately a patient-centric endeavor. Always keep the
needs and interests of your patients at the core when facilitating access to
their personal health data. It’s the ultimate smart long-term interoperability
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SACRAMENTO — California Democratic lawmakers so far have failed to convince Gov. Gavin Newsom that the state can afford to spend an estimated $2.6 billion a year to expand its Medicaid program to all unauthorized immigrants.
Now, they’re trying a new strategy.
Rather than working independently, a fiercely liberal state senator from Los Angeles and a moderate Assembly member from the Central Valley are joining forces to pressure Newsom to make California the first state in the nation to cover every income-eligible resident regardless of immigration status. Unauthorized immigrants up to age 26 can already qualify for Medi-Cal, the state’s Medicaid program for low-income residents.
Emboldened by the win of Democratic President-elect Joe Biden and spurred by the urgency of the coronavirus pandemic, state Sen. María Elena Durazo (D-Los Angeles) and Assembly member Joaquin Arambula (D-Fresno) plan to introduce a two-bill package on Monday that would cover unauthorized senior immigrants first, and eventually the remainder of California’s undocumented immigrant population.
“It’s a national issue. Look at how all the national Democratic candidates raised their hands in front of the world to support covering undocumented immigrants in health insurance,” Durazo told California Healthline. “We want a clear commitment to finally do this, not just lip service.”
Newsom has long touted his goal of achieving universal health coverage in California and made campaign promises to work toward a single-payer health care system. But after nearly two years in office, Newsom’s ambitious health care agenda has been sidetracked by deadly wildfires and a widening homelessness crisis — as well as the COVID-19 pandemic — and he has not managed to dramatically expand coverage.
California currently covers about 200,000 unauthorized immigrant children and young adults, according to the state Department of Health Care Services. The state budgeted about $375 million to cover young adults ages 19 through 25 this fiscal year, but does not track spending for undocumented immigrant children, according to the state Department of Finance.
Opening the low-income health program to all eligible undocumented immigrants would expand coverage to at least 915,000 low-income residents and cost an additional $2.6 billion annually, according to a projection this year by the nonpartisan state Legislative Analyst’s Office. There are an estimated 1.5 million undocumented immigrant Californians who are uninsured, estimates show, but not all of them would qualify.
Public support for expanding coverage to unauthorized immigrants has risen over the past few years, according to the Public Policy Institute of California. But expending scarce taxpayer resources on such an effort is politically risky, said Doug Herman, a Los Angeles-based national Democratic strategist.
“Gavin’s got bigger priorities right now and he has been wounded, so he has to be very cautious about what he does,” Herman said. “Look at the French Laundry and [Employment Development Department] scandals. The homelessness crisis is raging and the prison outbreak happened on his watch. This doesn’t rise to that level.”
Newsom communications director Jesse Melgar said no one from his office was available for comment.
Since Newsom took office, Durazo and Arambula have authored separate bills to expand Medi-Cal to more undocumented immigrants. Durazo has gotten close after negotiating with Newsom — only for the first-term Democratic governor to back out, citing costs.
Such proposals have received widespread legislative support among Democratic lawmakers, who hold supermajority power in both houses of the state legislature.
A worsening economic outlook and long-term budget pressures could once again derail their efforts. Because the federal government prohibits states from using federal Medicaid dollars to cover undocumented immigrants — except for emergency services — California would have to pick up most of the price tag, which could top $3 billion annually to cover everyone, including children and adults, according to the Legislative Analyst’s Office.
Newsom will be forced to weigh an onslaught of budget demands while managing, and paying for, the ongoing COVID-19 emergency.
“That gives Newsom the ability to delay or oppose anything that doesn’t fit his agenda,” Herman said.
But some lawmakers, immigration rights activists and health care advocates argue the COVID pandemic has made their campaign more urgent as Latino and Black residents get sick and die at disproportionate rates.
Politicians cannot ignore that the pandemic has exposed a broken health care system that has left millions of taxpaying Californians without health coverage because their immigration status renders them ineligible, said Sarah Dar, director of health and public benefits for the California Immigrant Policy Center, which is already lobbying the governor to support the Medi-Cal expansion.
“Now we have a full picture of what this crisis is, and the blatant disparities faced by our essential workers, so there’s no excuse,” she said. “Immigrant communities and farmworkers in the food and agricultural sector, like meatpacking plants, have literally been hotbeds for the spread of disease.”
Dar acknowledged financial pressures ahead for the state, and said advocates will be pushing for ways to generate money to pay for the expansion, possibly including tax increases.
There could be some hope for a one-time cash infusion. Fiscal estimates show California could reap a $26 billion surplus next year, largely from personal income tax receipts from high-income earners who have not suffered devastating economic losses during the pandemic, according to state fiscal analysts. Durazo and Arambula are eyeing that revenue for the Medi-Cal expansion.
“He has routinely stated his vision, but we’d like Gov. Newsom to deliver on health care for all during his governorship,” Arambula said. “I’m not going to sit and wait.”
Durazo said she would introduce a bill Monday to expand Medi-Cal to unauthorized immigrant Californians age 65 and older. She put a similar bill on hold in 2019, in exchange for a commitment from Newsom to include the proposal in this year’s state budget.
Durazo and other backers decided to craft a new approach: Alongside Durazo’s bill to cover older adults, Arambula plans to introduce companion legislation to cover all undocumented immigrant adults.
The lawmakers are using the two bills as a negotiating tactic. Arambula and advocates said they hope to win coverage for undocumented immigrants 65 and older next year, while developing a plan with Newsom to expand coverage to the entire population at some point during his governorship.
Durazo said both bills are equally important and are intentionally being used to pressure the governor into action next year.
“This is our way to finally have a real conversation about what it’ll take to get everyone covered, given we’ll have federal partners with the Biden-Harris administration,” said Orville Thomas, director of government affairs for the California Immigrant Policy Center.
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What You Should Know:
– CommonHealth has connected to 230
health systems in the United States, allowing patients to gather, manage and
share their health and test data, including COVID test and vaccination status. By
the end of this month, CommonHealth will connect to more than 340 health
– CommonHealth extends the health data
portability and interoperability model pioneered by Apple Health to the 55
percent of Americans with Android devices (85 percent globally)
The Commons Project, a nonprofit public trust established to build digital platforms and services for the public good, today announced that the CommonHealth app has now connected to 230 health systems in the United States, allowing patients using those health systems to gather, manage and share personal health information – including COVID test and vaccine status – on Android devices for free. CommonHealth enables broader and more equitable participation in remote consultations with doctors, telemedicine, innovative care models, next-generation health services, and research.
CommonHealth App Development Background
Developed in collaboration with UCSF, Cornell Tech, and Sage Bionetworks with a team of clinicians, public health experts, technologists, scientists and privacy advocates, CommonHealth is operated by The Commons Project. CommonHealth was first deployed at UCSF Health and underwent substantial testing and user experience research in multiple diverse populations in San Francisco. CommonHealth is the first and only platform designed to allow users of the Android operating system to collect and manage their health data on their mobile devices in a similar way that Apple Health Record operates on iOS.
Already integrated with LabCorp, which
operates one of the largest clinical laboratory networks in the world,
CommonHealth allows individuals to store their COVID test results and vaccination
status, in addition to any health record. CommonHealth plans to integrate with
an additional 110 health systems in December, connecting to more than 340
health systems before the year ends.
Earlier this year, the Center for Medicare and Medicaid (CMS) rolled out new patient health record sharing rules that will require hospitals and physician offices to send standardized medical information, such as lab test results, vaccination records, and imaging tests, directly to third-party apps, like CommonHealth, by July 2021.
Why It Matters
“The COVID pandemic has accelerated the need for the safe sharing of health data as medical consultations go online and individuals are required to demonstrate COVID test and vaccination status in order to travel, work, study and undertake other social activities,” said JP Pollak, co-founder and chief architect at The Commons Project. “CommonHealth extends the privacy-centered data portability and interoperability model pioneered by Apple Health to the 55 percent of Americans who have Android devices.”
CommonHealth is a shared public service that is always free
for users and is available for download on Android devices via Google Play: https://play.google.com/store/apps/details?id=org.thecommonsproject.android.phr
When doctors know their patients have been to the hospital, they can act fast to provide needed support. Widespread use of hospital event notifications is associated with all kinds of health benefits, including a 10 percent decrease in readmissions for Medicare beneficiaries. These event notifications are one of the simplest, easiest (most-bipartisan!), and most impactful changes we can make to improve patient outcomes in U.S. healthcare.
To this goal, the Centers for Medicare and Medicaid Services (CMS) released new regulations in March that will require hospitals to share event notifications with community providers when a patient is admitted, discharged, or transferred (ADT). Hospitals have to comply by May 2021 if they want to keep getting paid by Medicare and Medicaid.
This policy will improve care, reduce costs, and save lives. It’s also simple and straightforward. CMS explains, “Lack of seamless data exchange in healthcare has historically detracted from patient care, leading to poor health outcomes, and higher costs.” ADT notifications close these gaps and many healthcare organizations have been using them for years, vastly improving care for patients.
Take the Utah Health Information Network (UHIN) which has utilized ADT notifications to reduce costs and readmissions for over a decade. According to the former UHIN President and CEO, Teresa Rivera,
“This level of care coordination quite literally saves both lives and money.” She continues, “This secure and cost-effective method provides the patient’s entire medical team, regardless of where they work, with the important information they need to coordinate care. That coordination is important to reducing readmission rates, and helps health care professionals provide a better experience to patients.”
ADT notifications are a standard set of messages that most electronic health record (EHR) systems can generate with minimal set-up. In fact, in a 2019 letter from the National Association of ACOs in support of CMS’ proposal to require hospitals participating in Medicare and Medicaid to send event notifications, they expressed that new standards efforts are not needed for the successful implementation.
The authors wrote, “In numerous conversations with HIEs, other intermediaries and providers, we were unable to find a single example where a hospital was unable to send an ADT notification today due to lack of standards.”
But you wouldn’t know it if you listened to the misconceptions that are currently being spread to hospitals about this requirement. Here are five myths that I’ve encountered just this month:
Myth 1: The ADT notification policies are strict and difficult to comply with. Not true. CMS listened to feedback that Meaningful Use requirements were too regimented and promoted a “check the box” not “get it done” mentality. CMS purposely worked to keep these ADT requirements broad and non-prescriptive. Hospitals don’t need to comply with any specific technical standard. The CMS regulations released in March are final.
Myth 2: You have to connect to a nationwide network. Wrong. Hospitals can choose from a wide variety of regional and statewide health information exchange (HIE) partners. The policy requires “reasonable effort” to send notifications to providers in your community. An intermediary can be used to comply with the rule as long as it “connects to a wide range of recipients.” Unlike what some nationwide companies are saying, the regulations do not mandate out-of-state alerts.
Myth 3: The policy creates a big technical burden for hospitals. More than 99 percent of hospitals have EHR systems in place today, and most of those can produce standard ADT transactions with relatively minimal effort. While the time to activate ADT notifications varies, it can usually be done in as little as a day by a hospital IT team.
Myth 4: The timing isn’t right. It’s happening too fast. A global pandemic is exactly the moment when we need this kind of data sharing in our communities. With COVID-19, it is even more crucial that care teams are alerted promptly when a patient is seen in the emergency department or discharged from the hospital so that they can reach out and provide support. Regardless, CMS has given an additional six months of enforcement discretion for hospitals, pushing back the deadline to May 2021.
Myth 5: There’s no funding available for this work. Wrong again. In California and several other states, hospitals can take advantage of public funding to connect to regional HIEs that provide ADT notification services. There’s $50 million in funding available just in California.
This new policy is an exciting step forward for patients and providers. It gives primary care and post-acute providers crucial, needed information to improve patient care. Hospitals can meet the requirements with minimal burden using existing technologies. Patients will have a more seamless experience when they are at their most vulnerable.
In healthcare, it’s easy to assume that great impact requires great complexity. But time and again the opposite is true. So let’s bust the myths, get it done, and keep it simple.
About Claudia Williams
Claudia Williams is the CEO of Manifest MedEx. Previously the senior advisor for health technology and innovation at the White House, Claudia helped lead President Obama’s Precision Medicine Initiative. Before joining the White House, Claudia was director of health information exchange at HHS and was director of health policy and public affairs at the Markle Foundation.
The contracts are complicated and full of risks for drug companies. But there’s also a risk to steering clear of the arrangements — reduced or restricted access to a company’s medication.
Healthcare can achieve optimum efficiency when patients are at the center of care. When patients have the necessary information to navigate their care journey, they will choose the path to high-quality care at the lowest costs. Cost-sharing and insurance premiums are rising consistently since the last decade for employer plans, which covers nearly half of the country’s population. Plan members are shouldering a part of the healthcare cost burden, so they want to keep it as low as possible. At the same time, they want maximum value for their money with access to quality care.
CMS identified this as an opportunity and issued the Final Interoperability and Patient Access rule. The rule allows patients to access electronic health data through any third-party application of their choice. The rule intends to allow patients to take control of their data and determine who can see which data. It will also make transferring data from provider to provider easier. So that patients can be ensured that their provider is fully aware of their medical history.
The Challenge of Providing Members Access to Healthcare Data
The biggest challenge that health plans will face is to extract data from multiple sources in-house, clean and scrub it, and ensure it is in the appropriate format as required by the Centers for Medicare and Medicaid Services (CMS). Some health plans have been in business for a really long time. Patient data has been accumulating through these years in legacy systems. Providing access to that data through certified third-party applications will require a lot of effort on the part of health plans. The health plans also have to ensure tight authentication standards so that only the people requested by the members have access to their healthcare data.
In addition, there are multiple problems associated with provider data. Incorrect data in the provider database costs close to $3 billion annually. CMS has also issued warnings for inaccurate provider directories, high claim-reprocessing volumes, and substantial encounter-data rejection rates. Payers have been addressing the data issues with short term solutions. But now they have to resolve the provider data problems for good and make health data readily available to the members.
The COVID Crisis Upended The Payer Compliance Initiatives
Payers are in solidarity with providers and patients in this time of crisis. While providers work tirelessly to help an increased number of patients access the required care, payers are providing support through fast track reimbursements and reduced utilization management.
Many health plans are focused on ensuring that their members have access to resources to fight COVID, which is why CMS extended the deadline for the Final Interoperability rule. Utilization patterns are witnessing a significant change. Many members are not receiving scheduled care as some elective surgeries are rescheduled and some provider offices are shut down. There has been a drop in certain kinds of utilization. Conversely, there has been a dramatic surge in telehealth office visits and behavioral health services.
The Road Ahead for Health Plans
Healthcare payers have endured significant claims-based, economic, and operational challenges during the pandemic. While they battle those bottlenecks, they also have to ascertain and prepare for the future and devise ways to ensure that their members have access to quality care.
Health plans will have to try to anticipate what utilization patterns will look like in the future, especially in the next year. Telehealth utilization will not be the same as it was pre-COVID. They will also have to ensure that members have access to care. They will have to reach out to members, especially those who are the most vulnerable. They will have to make sure members are not suffering from social isolation, they are taking their medication and they have access to transportation to get to the doctor.
Provider Alliance for CMS Compliance
CMS is handing over the reins of the care journey to the patients to improve care delivery through the Interoperability rule. Providers will play a key role in enabling access to healthcare data to patients by streamlining data and closing coding gaps. Payers must assist providers with their data needs to ensure compliance with the CMS rules.
As the pandemic ends and CMS comes out with more definitive long term rules and coverages, it is going to be important to ensure that providers are on the same page with payers. Health plans can partner with providers to educate them about the acceptable telehealth codes and what type of services are to be performed using those codes. Providers want to take care of their patients and they want to do it well. They want to leverage technology to ensure patient access to care and ensure their safety, especially for patients who suffer from multiple comorbidities.
About Elizabeth Bierbower
Elizabeth Bierbower is a strategic leader with more than thirty years of executive experience in the health insurance industry. She has experience scaling cost-effective and profitable growth strategies through internal innovation, and a reputation as being one of the industry’s most fiscally responsible and progressive leaders. Bierbower currently serves on the Boards of Iora Health, the American Telemedicine Association, and is on Innovaccer’s Strategic Advisory.
Previously Beth was a member of Humana’s Executive Management Team and held various roles including Segment President, Group and Specialty Benefits, and was an Enterprise Vice President leading Humana’s Product Development and Innovation teams.
There are plenty of other Medicare ads, too, many set against a red-white-and-blue background meant to suggest officialdom — though if you stand about a foot from the television screen, you might see the fine print saying they are not endorsed by any government agency.
Rather, they are health insurance agents aggressively vying for a piece of a lucrative market.
This is what Medicare’s annual enrollment period has come to. Beneficiaries — people who are 65 or older, or with long-term disabilities — have until Dec. 7 to join, switch or drop health or drug plans, which take effect Jan. 1. By switching plans, they can potentially save money or get benefits not ordinarily provided by the federal insurance program.
For all its complexity and nearly endless options, Medicare fundamentally boils down to two choices: traditional fee-for-service or the managed care approach of Medicare Advantage.
The right choice for you depends on your financial wherewithal and current health status, and on future health scenarios that are often difficult to foresee and unpleasant to contemplate.
Costs and benefits among the multitude of competing Medicare plans vary widely, and the maze of rules and other details can be overwhelming. Indeed, information overload is part of the reason a majority of the more than 60 million people on Medicare, including over 6 million in California, do not comparison-shop or switch to more suitable plans.
“I’ve been doing it for 33 years and my head still spins,” says Jill Selby, corporate vice president of strategic initiatives and product development at SCAN, a Long Beach nonprofit that is one of California’s largest purveyors of Medicare managed care, known as Medicare Advantage. “It’s definitely a college course.”
Which explains why airwaves and mailboxes are jammed with all that promotional material from people offering to help you pass the course.
Many are touting Medicare Advantage, which is administered by private health insurers. It might save you money, but not necessarily, and research suggests that, in some cases, it costs the government more than administering traditional Medicare.
But the hard marketing is not necessarily a sign of bad faith. Licensed insurance agents want the nice commission they get when they sign somebody up, but they can also provide valuable information on the bewildering nuances of Medicare.
Industry insiders and outside experts agree most people should not navigate Medicare alone. “It’s just too complicated for the average individual,” says Mark Diel, chief executive officer of California Coverage and Health Initiatives, a statewide association of local outreach and health care enrollment organizations.
However, if you decide to consult with an insurance agent, keep your antenna up. Ask people you trust to recommend agents, or try eHealth or another established online brokerage. Vet any agent you choose by asking questions on the phone.
“Be careful if you feel like the insurance agent is pushing you to make a decision,” says Andrew Shea, senior vice president of marketing at eHealth. And if in doubt, don’t hesitate to get a second opinion, Shea counsels.
You can also talk to a Medicare counselor through one of the State Health Insurance Assistance Programs, which are present in every state. Find your state’s SHIP at www.shiptacenter.org.
The website offers a deep dive into all aspects of Medicare. If you type in your ZIP code, you can see and compare all the Medicare Advantage plans, supplemental insurance plans, known as Medigap, and stand-alone drug (Part D) plans.
The site also shows you quality ratings of the plans, on a five-star scale. And it will display your drug costs under each plan if you type in all your prescriptions. Explore the website before you talk to an insurance agent.
California Coverage and Health Initiatives can refer you to licensed insurance agents who will provide local advice and enrollment assistance. Call 833-720-2244. Its members specialize in helping people who are eligible for both Medicare and Medicaid, the health insurance program for low-income people.
These so-called dual eligibles — nearly 1.5 million in California and about 12 million nationwide — get additional benefits, and in some cases they don’t have to pay Medicare’s monthly medical (Part B) premium, which will be $148.50 in 2021 for most beneficiaries, but higher for people above certain income thresholds.
If you choose traditional Medicare, consider a Medigap supplement if you can afford it. Without it, you’re liable for 20% of your physician and outpatient costs and a hefty hospital deductible, with no cap on how much you pay out of your own pocket. If you need prescription drugs, you’ll probably want a Part D plan.
Medicare Advantage, by contrast, is a one-stop shop. It usually includes a drug benefit in addition to other Medicare benefits, with cost sharing for services and prescriptions that varies from plan to plan. Medicare Advantage plans typically have low to no premiums — aside from the Part B premium that most people pay in either version of Medicare. And they increasingly offer additional benefits, including vision, dental, transportation, meal deliveries and even coverage while traveling abroad.
Beware of the risks, however.
Yes, the traditional Medicare route is generally more expensive upfront if you want to be fully covered. That’s because you pay a monthly premium for a Medigap policy, which can cost $200 or more. Add to that the premium for Part D, estimated to average $41 a month in 2021, according to KFF. (KHN is an editorially independent program of KFF.)
However, Medigap policies will often protect you against large medical bills if you need lots of care.
In some cases, Medicare Advantage could end up being more expensive if you get seriously ill or injured, because copays can quickly add up. They are typically capped each year, but can still cost you thousands of dollars. Advantage plans also typically have more limited provider networks, and the extra benefits they offer can be subject to restrictions.
The main appeal of traditional Medicare is that it doesn’t have the rules and restrictions of managed care.
Dr. Mark Kalish, a retired psychiatrist in San Diego, says he opted for traditional fee-for-service with Medigap and Part D because he didn’t want a “mother may I” plan.
“I’m 69 years old, so heart attacks happen; cancer happens. I want to be able to pick my own doctor and go where I want,” Kalish says. “I’ve done well, so the money isn’t an issue for me.”
Be aware that if you don’t join a Medigap plan during a six-month open enrollment period that begins when you enroll in Medicare Part B, you could be denied coverage for a preexisting condition if you try to buy one later.
There are a few exceptions to that in federal law, and four states — New York, Massachusetts, Maine, Connecticut — require continuous or yearly access to Medigap coverage regardless of health status.
Make sure you understand the rules and exceptions that apply to you.
Indeed, that is an excellent rule of thumb for all Medicare beneficiaries. Read up and talk to insurance agents and Medicare counselors. Talk to friends, family members, your doctor, your health plan — and other health plans.
When it comes to Medicare, says Erin Trish, associate director of the University of Southern California’s Schaeffer Center for Health Policy and Economics, “it takes a village.”
This KHN story first published on California Healthline, a service of the California Health Care Foundation.
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In October, Mary Mayhew became the association’s CEO. Mayhew, who led the state’s Medicaid agency since 2019, has been a vocal critic of the Affordable Care Act’s Medicaid expansion adopted by 38 other states. She has argued that expansion puts states in a difficult position because the federal government is unlikely to keep its financial commitment to pay its share of the costs.
Had Medicaid been expanded in Florida, hospitals there would have gained thousands of paying patients. But the institutions have done little in recent years to persuade the Republican-led legislature and Gov. Ron DeSantis, also Republican, who oppose such a move.
Mayhew acknowledged in an interview with KHN that expanding Medicaid to cover more uninsured patients could help hospitals financially, especially at a time when facilities have seen demand for services decline as people avoid care for fear of contracting COVID-19.
With that in mind, she said, she is now open to the idea of expanding Medicaid. “We need to look at all options on the table,” she said. “Is it doable? Yes.”
Still, she was quick to point out concerns about whether Florida can afford to expand.
Under the ACA, the federal government pays 90% of the costs for newly enrolled Medicaid recipients. In the traditional Medicaid program — which covers children, people who are disabled and pregnant women — the federal government pays nearly two-thirds of Florida’s Medicaid costs.
“It will be financially challenging in our state budget as revenues have dropped,” Mayhew said, echoing comments of state officials. “That 10% cost has to come from somewhere.”
Mayhew’s hire worries advocates who have spent more than seven years lobbying lawmakers to expand Medicaid. Without strong support from the hospital industry, they fear they’re unlikely to change many votes.
“It may make it harder,” said Karen Woodall, executive director of Florida People’s Advocacy Center, a group that lobbies for policies to help low-income citizens. Marshaling hospital support is important, she said, because of the industry’s money and political clout.
In many state capitals, hospitals have led the fight for Medicaid expansion either by lobbying lawmakers or bankrolling ballot initiatives. The latest example was in Missouri, which this summer expanded Medicaid via a voter initiative. The campaign for the measure was partly funded by hospitals.
But in Florida, hospitals appear to have made a calculated decision to avoid pushing an initiative that Republican leaders have said they don’t want. Among the dozen states that have not expanded Medicaid, Florida is second only to Texas in the number of residents who could gain coverage.
Aurelio Fernandez, CEO of Memorial Healthcare System in Hollywood, Florida, who was chair of the hospital association board when it hired Mayhew, said her opposition to Medicaid expansion never came up in the process. The association hired Mayhew because of the “phenomenal job” she did guiding hospitals amid the COVID pandemic, he said.
“There is no appetite at this juncture [for the legislature] to expand the Medicaid program with Obamacare,” said Fernandez, despite his belief that expansion would help hospitals and patients.
Mayhew, sounding more like a state official than a hospital industry spokesperson, said the ultimate decision on expansion will be up to lawmakers, who must review spending priorities. When states face a financial crunch, lawmakers look to reduce spending in education and Medicaid, which are the biggest parts of the budget, she said.
“The last thing we want to see is the state budget balanced on the backs of hospitals with deep Medicaid reimbursement cuts,” Mayhew said.
Mayhew said her previous opposition to expanding Medicaid occurred when she was responsible for balancing the state budget and managing the programs in Florida and, before that, in Maine. When she ran Maine’s program, she said she opposed expanding Medicaid to allow nondisabled adults into the program while there were disabled enrollees already on waiting lists to get care.
The Florida Hospital Association, which represents more than 200 hospitals, spent years lobbying state lawmakers to expand Medicaid. But since DeSantis was elected in 2018, the group has focused on other issues because the governor and Republican lawmakers made clear they would not expand the program.
Asked what the association’s current position is on Medicaid expansion, Mayhew noted she has been in her job less than a month and “we have not had that policy decision by the board for me to answer that.”
Miriam Harmatz, executive director of the Florida Health Justice Project, an advocacy group, said Mayhew’s hire suggests that hospitals are unlikely to get behind a fledgling effort to put the expansion question to voters in 2022.
Others advocating for Medicaid expansion agree.
“It does not look like they [Florida’s hospitals] are on board with helping us expand Medicaid at the moment,” said Louisa McQueeney, program director of Florida Voices for Health, a consumer group helping with the ballot initiative.
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But in January, Angevine’s pharmacy on Long Island ran out of oxymorphone and he couldn’t find it at other drugstores. He fell into withdrawal and had to be hospitalized.
“You just keep thinking: Am I going to get sick? Am I going to get sick?” Angevine said in a phone interview. “Am I going to be able to live off the pills I have? Am I going to be able to get them on time?”
His pharmacy did not tell him the reason for the shortage. But Angevine isn’t the only pain patient in New York to lose access to vital medicine since July 2019, when the state implemented an excise tax on many opioids.
The tax was touted as a way to punish major drugmakers for their role in the opioid epidemic and generate funding for treatment programs. But to avoid paying, scores of manufacturers and wholesalers stopped selling opioids in New York. Instead of the anticipated $100 million, the tax brought in less than $30 million in revenue, two lawmakers said in interviews. None of it was earmarked for substance abuse programs, they said.
The state’s Department of Health, which has twice this year delayed an expected report on the impact of the tax, did not respond to questions for this story.
The tax follows strong efforts by federal and New York officials to tamp down the use of prescription opioids, which had already cut back some supply. Now, with some medications scarce or no longer available, pain patients have been left reeling. And the law appears to have missed its target: Instead of taking a toll on manufacturers, the greater burden appears to have fallen on pharmacies that can no longer afford or access the painkillers.
Among them is Epic Pharma. Independent Pharmacy Cooperative, a wholesaler, confirmed it no longer sells medications subject to the tax, but still sells those that are exempt, which are treatments for opioid addiction methadone and buprenorphine and also morphine. AvKARE and Lupin Pharmaceuticals said they do not ship opioids to New York anymore. Amneal Pharmaceuticals, which manufactures Angevine’s oxymorphone, declined to comment, as did Mallinckrodt.
Since the tax went into effect, Cardinal Health, which provides health services and products, published an extensive 10-page list of opioids it does not expect to carry. Cardinal Health declined to comment.
The New York tax is slowly gaining attention in other states. Delaware passed a similar tax last year. Minnesota is assessing a special licensing fee between $55,000 and $250,000 on opioid manufacturers. New Jersey Gov. Phil Murphy proposed such a tax this year but was turned down by the legislature.
The company that makes the first point of sale within New York pays the tax. That isn’t always the drugmaker. It can mean wholesalers selling to pharmacies here are assessed, explained Steve Moore, president of the Pharmacists Society of the State of New York.
Independent Pharmacy Cooperative said about half its revenue from opioid sales in New York would have gone to taxes.
Mark Kinney, the company’s senior vice president of government relations, said the law is putting companies in a very difficult position.
When wholesalers like IPC left the opioid market, competitive prices went with them.
Without these smaller wholesalers, it’s hard for pharmacies to go back to other wholesalers “and say, ‘Hey, your prices aren’t in line with the rest of the market,’” Moore said.
Indeed, nine independent pharmacies told KHN that when they can get opioids they are more expensive now. They have little choice but to eat the cost, drop certain prescriptions or pass the expense along.
“We can trickle that cost down to the patient,” said a pharmacist at New London Pharmacy in Manhattan, “but from a moral and ethics point of view, as a health care provider, it just doesn’t seem right to do that. It’s not the right thing to ask your patient to pay more.”
In addition, Medicare drug plans and Medicaid often limit reimbursements, meaning pharmacies can’t charge them more than the programs allow.
Stone’s Pharmacy in Lake Luzerne was losing money “hand over fist,” owner Leigh McConchie said. His distributor was adding the tax directly to his pharmacy’s cost for the drugs. That helped drive down his profit margins from opioid sales between 60% and 70%. Stone’s stopped carrying drugs like fentanyl patches and oxycodone, and though that distributor now pays the tax itself, the pharmacy is still feeling the effects.
“When you lose their fentanyl, you generally lose all their other prescriptions,” he said, noting that few customers go to multiple pharmacies when they can get everything at one.
If pharmacies have few opioid customers, those price hikes have less impact on their business. But being able to manage the costs is not the only problem, explained Zarina Jalal, a manager at Lincoln Pharmacy in Albany. Jalal can no longer get generic oxycodone from her supplier Kinray, though she can still access brand-name OxyContin. New York’s Medicaid Mandatory Generic Drug Program requires insurers to provide advance authorization for the use of brand-name prescriptions, delaying the approval process. Sometimes patients wait several days to get their prescription, Jalal explained.
“When I see them suffer, it hurts more than it hurts my wallet,” she said.
One of Jalal’s customers, Janis Murphy, needs oxycodone to walk without pain. Now she is forced to buy a brand-name drug and pays up to three times what she did for generic oxycodone before the tax went into effect. She said her bill since the start of this year for oxycodone alone is $850. Lincoln Pharmacy works with Murphy on a payment plan, without which she would not be able to afford the medication at all. But the bill keeps growing.
“I’m almost in tears because I cannot get this bill down,” she said in a phone interview.
Several pharmacists raised concerns that patients who lose access to prescription opioids may turn to street drugs. High prescription prices can drive patients to highly addictive and inexpensive heroin. McConchie of Stone’s Pharmacy said he now dispenses twice as many heroin treatment drugs as he did a year ago. Former opioid customers now come in for prescriptions for substance use disorder.
Trade groups and some physicians and state legislators opposed the tax before it went into effect, voicing concerns about a slew of potential consequences, including supply problems for pharmacists and higher consumer prices.
New London Pharmacy said one of its regular distributors stopped shipping Percocet, a combination of oxycodone and acetaminophen. Instead, the pharmacy orders from a more expensive company. The pharmacist estimated that a bottle of Percocet for which it used to pay $43 now costs up to $92.
“Even if we absorb the tax, we’re not getting a break from reimbursements either,” a pharmacist who spoke on the condition of anonymity explained, adding that insurance reimbursements have not increased in proportion to rising drug costs. “We’re losing.”
Latchmin Raghunauth Mondol, owner of Viva Pharmacy & Wellness in Queens, has also seen that problem. The pharmacy used to be able to purchase 100 15-milligram tablets of oxycodone for $15, but that’s now $70, she said, and the pharmacy is reimbursed only about $21 by insurers.
Other opioids are just not available.
Mondol said she has been unable to obtain certain doses of two of the most commonly prescribed opioids, oxycodone and oxymorphone — the drug Angevine was on.
After Angevine lost access to oxymorphone, his doctor put him on morphine, but it does not give him the same relief. He’s been in so much pain that he stopped going to physical therapy appointments.
“It’s a marathon from hell,” he said.
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Attorneys for GOP-controlled states seeking to kill the Affordable Care Act told the Supreme Court last week that at least some of the 12 million people who newly enrolled in Medicaid signed up only because of the law’s requirement that people have insurance coverage — although a tax penalty no longer exists.
The statement drew a rebuke from Justice Sonia Sotomayor, who said it belies reason. Several health experts also questioned the argument that poor people apply for Medicaid not because they need help getting health care but to meet the ACA’s individual mandate for coverage.
The point is vital to the Republicans’ case to overturn the ACA, an effort supported by the Trump administration. The states are trying to prove they were harmed by the 2010 health law — and thus have “legal standing” to challenge its constitutionality. They argue their Medicaid spending increased because of the mandate, even though Congress eliminated the tax penalty for not having health coverage in 2019. Even when the penalty existed, most poor people were exempt because of their low income.
Under the ACA, states can opt to expand Medicaid eligibility to all adults earning less than 138% of the federal poverty level, or about $17,600 for an individual. States and the federal government share the cost of their care.
If the states cannot prove they have standing, the justices can toss their case without ruling on its merits. The case also involves two individuals who purchased private insurance from Texas and are suing to have the law overturned.
The Medicaid costs issue was one of several ways Texas and other GOP-controlled states participating in the lawsuit say they were harmed by the ACA even after the individual mandate penalty was reduced to zero. Several justices, including conservatives Clarence Thomas and Amy Coney Barrett, posed questions about whether the states had standing.
The case heard last Tuesday, California v. Texas, was the third time the high court has taken up a major suit on the ACA. Republican attorneys general in 18 states and the Trump administration want the entire law struck down, a move that would threaten coverage for more than 20 million people, as well as millions of others with preexisting conditions, including COVID-19.
Even if the court rules the states have legal standing, the ACA opponents must prove the elimination of a penalty makes the entire law unconstitutional.
The Republican states assert that since the law was upheld under Congress’ taxing powers by the Supreme Court in 2012, once the tax penalty is gone, the entire law must fall, too.
A group of Democratic-controlled states led by California and the Democratic House of Representatives are urging the court to keep the law in place.
Sotomayor raised serious doubts about the plaintiffs’ Medicaid argument and whether the states had suffered injury.
“At some point, common sense seems to me would say: Huh?” Sotomayor told Kyle Hawkins, Texas’ solicitor general, who is leading the GOP states’ legal fight. She questioned whether it seemed reasonable that once Medicaid enrollees are told there is no tax penalty for people who don’t have coverage they would “enroll now, when they didn’t enroll when they thought there was a tax? Does that make any sense to you?”
Hawkins defended his case, saying states need to show that only one person signed up for Medicaid because of the individual mandate. “There’s a substantial likelihood of at least one person signing up for a state Medicaid program, which, of course, would cause at least one dollar in injury and satisfy the standing requirement,” he said.
He cited a Congressional Budget Office report issued in 2017, when lawmakers were considering the change in the penalty. It said some people would continue to buy insurance or seek coverage “solely because of a willingness to comply with the law,” even if the individual mandate penalty were eliminated.
Few surveys have asked Medicaid enrollees why they signed up for the program.
One of them, by University of Michigan researchers that same year, posed the question to 1,750 adults who had become eligible for Medicaid in the state as a result of the ACA expansion. The most common reasons respondents gave for enrolling were that they had lost other health coverage and had a medical condition that required care. Just 2% of respondents cited the need to avoid the individual mandate tax penalty.
With the tax penalty eliminated, legal and health policy experts said, it’s likely the share of respondents signing up for Medicaid because of the health coverage mandate has dropped closer to zero.
Richard Kay, a law professor emeritus at the University of Connecticut, said it’s clear most people don’t seek coverage because of the individual mandate — particularly since there is no longer a financial penalty. But there could be a few who still do.
“Do you stop at a stop sign if you are in the country and no one is around for miles?” he said. “It’s not impossible that some people get insurance just because the law requires them.”
Kay said there is no precise guidance on how courts decide whether a plaintiff has been penalized enough to prove it has legal standing. “It’s a very confused area of the law,” he said.
Pratik Shah, a Washington, D.C., attorney who represents America’s Health Insurance Plans, a trade group fighting to preserve the law, said the plaintiffs in the case have not proved standing.
“It does not make logical sense,” he said of the argument that state budgets were harmed by people signing up for Medicaid even after the individual mandate penalty was eliminated.
“It’s hard to see how the 2017 amendment to the health law would have forced more people into Medicaid,” he said. “If they weren’t signed up before, they would be less likely to get it without the penalty.”
The court is expected to rule on the case by the end of June.
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Over the past few months, primarily as a result of the COVID-19 pandemic, telehealth has gone from a “nice-to-have” to a “must-have” for healthcare providers. The surge of COVID-19 patients in the spring, coupled with “stay-at-home” orders in many states, meant that many patients in need of care for chronic conditions and other non-emergent health issues were unable to visit their providers face-to-face.
Telehealth became the emergency solution, aided by relaxation of government regulations and improved reimbursement from health payers, led by the U.S. Centers for Medicare and Medicaid Services (CMS). But then a funny thing happened.
As COVID-19 restrictions eased, many patients and providers found they liked telehealth and wanted to keep it around. Patients liked it because they didn’t have to take hours out of their day to travel to an appointment, go through COVID-19 protocols, wait to be called, wait to see their provider, then travel home again.
Providers liked it because they could work more efficiently and, if they were incorporating remote patient monitoring, obtain a more complete view of their patients’ day-to-day health. Both sides also liked telehealth because, quite frankly, it helped them reduce their risk of contracting a highly contagious virus.
While we are not out of the woods yet – many experts are predicting a fall and winter surge that will make the spring surge look like a warm-up act – there are already discussions about whether telehealth was simply a stopgap measure in a crisis or should be viewed as a standard option for care going forward. In order to make telehealth permanent, however, healthcare organizations will want to know exactly what it can contribute once it’s safe to venture to the office once again.
Advanced analytics can help. They can show what worked, and what didn’t, so providers can make data-driven decisions about where, how, and whether to continue using telehealth. The following are eight ways analytics can contribute to present and future telehealth success.
1. Find the patients for whom telehealth visits offer the greatest benefits. Normally, these will be patients who can be diagnosed or assessed without direct laying-on of hands. They may have a condition such as a rash that can be inspected visually or may be able to use consumer-grade devices to take and report biometric readings. Advanced analytics can help discover them, enabling providers to close care gaps while improving Star ratings and HEDIS scores.
2. Prioritize patients by need. Analytics can help identify patients who are most at-risk of deterioration if they do not follow-up after preventive or elective procedures or are not closely monitored. They can also help providers make the appropriate adjustments to those priorities as patient health changes.
3. Get ready for additional surges. The next surge has already begun, and there are likely to be others before the pandemic is fully behind us. Providers need to have measures in place to keep staff safe and avoid the risk of more lockdowns or other changes that will disrupt their operations. Analytics can help them determine how much to invest in additional telehealth equipment and training to ensure uninterrupted service to their patients.
4. Measure telehealth’s impact on patient outcomes and reimbursement. Telehealth is so new, and the pandemic has caused so many shifts in reimbursement, that it can be difficult to determine exactly what effect it has had on outcomes and revenue. Analytics can uncover which changes have been positive and should be continued, and which should either be discontinued or adjusted to produce better health and/or financial result.
5. Uncover and rectify possible coding errors. As the pandemic took hold in March, CMS launched its “patients over paperwork” initiative. The goal was to ensure providers focused on care rather than worrying about coding accuracy, especially as the path to telehealth opened up. At some point, however, accurate coding will again be required. Analytics can help providers uncover and rectify any coding issues to ensure claims are paid fairly and completely.
6. Enable more effective remote patient monitoring. The presence of a global pandemic doesn’t halt chronic or other conditions affecting patient health. These conditions must continue to be managed to prevent them from deteriorating, which will place more of a health burden on patients while increasing long-term costs. Remote patient monitoring delivers the day-to-day data on these conditions. Analytics use that data to spot trends and update providers on the condition of all those patients, making it easier to ensure successful treatment for all of them.
7. Manage timed events more effectively. Risk-adjustment capture of previously documented conditions, which comes through CMS sweeps, retrospective reviews, and other means, can be disruptive to provider operations. Analytics can take the burden off an already exhausted staff by automating and simplifying the process.
8. Use trend and outcome data to inform the future. There is still much we don’t know about the effectiveness – and cost-effectiveness – of telehealth. This type of forward-looking analysis can be used to deliver policy and regulatory guidance for permanent reimbursement and best practices for telehealth-related visits.
As we continue to battle the global pandemic, telehealth does more each day to demonstrate its value. But what happens when the battle is finally won? Should it go back to the background or become fully integrated into a healthcare organization’s standard offerings?
Advanced analytics can be used to answer these questions and many others, helping providers make the decision that best fits their organization.
About Prasad Dindigal
Prasad Dindigal serves as Vice President, Healthcare & Life Sciences, with EXL, a leading operations management and analytics company that helps our clients build and grow sustainable businesses.
What You Should Know:
– The American Medical Association (AMA) published an
update to the Current Procedural Terminology (CPT®) code set that includes new
vaccine-specific codes to report immunizations for the novel coronavirus
– The new Category I CPT codes and long descriptors for the vaccine products 91300 and 91301 for better tracking, reporting, and analysis that supports data-driven planning and allocation.
The American Medical Association (AMA) today published an update to the Current Procedural Terminology (CPT®) code set that includes new
vaccine-specific codes to
report immunizations for the novel coronavirus (SARS-CoV-2).
New Category CPT Codes
The new Category I CPT codes and long descriptors
for the vaccine products are:
91300: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use
91301: Severe acute respiratory syndrome coronavirus
2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike
protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use
In accordance with the new vaccine-specific product CPT codes, the CPT Editorial Panel has worked with the Centers for Medicare & Medicaid Services to create new vaccine administration codes that are both distinct to each coronavirus vaccine and the specific dose in the required schedule. This level of specificity is a first for vaccine CPT codes, but offers the ability to track each vaccine dose, even when the vaccine product is not reported (e.g. when the vaccine may be given to the patient for free). These CPT codes report the actual work of administering the vaccine, in addition to all necessary counseling provided to patients or caregivers and updating the electronic record.
Admin CPT Codes & Long Descriptors
For quick reference, the new vaccine administration CPT codes and
long descriptors are:
0001A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose
0002A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose
0011A: Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 100 mcg/0.5mL dosage; first dose
0012A: Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative-free, 100 mcg/0.5mL dosage; second dose
All the new vaccine-specific CPT codes published in today’s update will be available for use and effective upon each new coronavirus vaccine receiving Emergency Use Authorization or approval from the Food and Drug Administration. In addition to the long descriptors, short and medium descriptors for the new vaccine-specific CPT codes can be accessed on the AMA website, along with several other recent modifications to the CPT code set that have helped streamline the public health response to the SAR-CoV-2 virus and the COVID-19 disease.
While it’s far too early to say what the first 100 days of a Biden administration will look like from a detailed policy perspective, the president-elect has made one point abundantly clear. It’s time to get to work — and that work starts with the COVID-19 pandemic.
“Our work begins with getting COVID under control,” Biden said during his victory speech. “We cannot repair the economy, restore our vitality or relish life’s most precious moments — hugging a grandchild, birthdays, weddings, graduations, all the moments that matter most to us — until we get this virus under control.”
As the United States inches closer toward the macabre milestone of 10 million total coronavirus cases, the Biden administration’s response to the ongoing pandemic will need to be wide-ranging and thorough, touching on everything from vaccine development and distribution, to additional rounds of relief for health care providers. Long-term care and protecting America’s senior population will also need to be at the very center of its response.
“I will spare no effort — or commitment — to turn this pandemic around,” Biden continued.
In the weeks and months leading up to his victory this past weekend, Biden — a soon-to-be 78-year-old man himself — suggested a deep appreciation of home-based care.
In July, for example, the former vice president outlined a $775 billion plan to overhaul the nation’s caregiving infrastructure, which is mostly made up of women and people of color. As part of that plan, Biden said he hoped to create upwards of 3 million new caregiving and education jobs over the next decade, while likewise creating pathways for former caregivers to re-enter the workforce.
The plan additionally called for a $450 million boost for senior care, with some of those funds dedicated to improving wages and labor conditions for in-home care workers.
“Home health workers do God’s work, but aren’t paid much,” the then presidential candidate said on social media. “They have few benefits, and 40% are still on SNAP or Medicaid. It’s unacceptable. I’ll give caregivers and early childhood educators a much-needed raise.”
Biden hasn’t just highlighted his appreciation of home-based care in broad strokes and policy promises. In addition to his $775 billion plan, the president-elect has repeatedly brought attention to very specific, innovative programs that typically only industry insiders know about.
That includes making nuts-and-bolts references to CAPABLE, the increasingly popular program out of the Johns Hopkins School of Nursing designed to support aging in place by coordinating nursing, therapy and handyman services in the home.
“To hear him really describe [CAPABLE] was thrilling,” Sarah Szanton, the Johns Hopkins professor who helped create the program, recently told Home Health Care News.
Protecting America’s seniors
Moving forward, Biden and his staff will likely try to secure additional resources for home-based care providers and other long-term care operators. In its official policy plan for nursing home regulations, for instance, the Biden team stated it would invoke the Defense Production Act to increase the overall supply of PPE.
The campaign was highly critical of the Trump administration for failing to coordinate sufficient distribution of testing supplies and personal protective equipment (PPE) early on, so a lack of action on that front would only be viewed as hypocritical.
Currently, “protecting older Americans” is one of the main priorities featured on the Biden-Harris Transition website. That fact that hasn’t gone overlooked by those in the aging services space.
“We appreciate the Biden-Harris Transition team’s announcement regarding its COVID-19 response,” Argentum CEO James Balda said in a statement. “The specific emphasis on protecting at-risk populations, which includes older adults and those who serve them, as well as a focus on the efficacy of vaccine distribution, is critical to controlling the spread of this virus.”
Argentum is the country’s largest senior living association.
The Biden-Harris Transition team announced the formation of its 13-person Transition COVID-19 Advisory Board on Monday. The advisory board will be led by former FDA Commissioner Dr. David Kessler, former Surgeon General Dr. Vivek Murthy and Dr. Marcella Nunez-Smith, a Yale physician and researcher.
“Dealing with the coronavirus pandemic is one of the most important battles our administration will face, and I will be informed by science and by experts,” President-Elect Biden said Monday.
Notably, the advisory board also includes Dr. Atul Gawande, the surgeon and writer who founded Ariadne Labs, a joint center between Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health.
Gawande — former CEO of Haven, the health care venture founded by Amazon, Berkshire Hathaway and JPMorgan Chase — has been a staunch supporter of palliative medicine and end-of-life care. His participation on the board could signal a focus on those areas during the duration of the public health emergency.
The Coalition to Transform Advanced Care (C-TAC) said it has been encouraged by a number of Biden campaign proposals that have the potential to improve the lives of the seriously ill, particularly in home- and community-based settings.
“C-TAC looks forward to forging new relationships with those in the incoming Biden administration and Congress,” C-TAC Executive Director Jon Broyles said in a statement. “As we work toward building a health care system that works for everyone, it is essential that we come together to find innovative solutions that meet the needs of the sickest and most vulnerable among us, with particular attention to low-income, traditionally underserved individuals.”
Beyond home care
The advisory board may include others in days to come.
Given the pandemic’s outsized impact on people age 65 and older, additional expertise in aging — whether via gerontologists, industry leaders or researchers — would bring much value, according to Ruth Katz, LeadingAge’s senior vice president of policy. LeadingAge is a diverse association of nonprofit providers of aging services.
“We expect to see a focus on in-home and community-based services through programs in their platform on caregiving, education and workforce,” Katz said in a statement. “That’s a positive.”
Beyond directly supporting home-based care, a Democratic president in the White House and a split Congress may also mean a heightened willingness to reach across the aisle to get things done, at least compared to the past four years.
Initially, there’s bound to be friction between both governing parties, a concept reflected in the largely unsubstantiated voter-fraud concerns voiced by Republican leadership. Over time, though, lawmakers will hopefully find common ground on no-brainer, common-sense issues.
That could mean newfound momentum behind legislation with bipartisan support, such as the Home Health Emergency Access to Telehealth (HEAT) Act, a bill to provide Medicare reimbursement for audio and video telehealth services delivered by home health agencies during a public emergency. Among the bill’s backers is Sen. Susan Collins of Maine, one of the few Republicans to officially congratulate Biden on his victory.
It could also mean continued support for Medicare Advantage (MA), which, in turn, means continued support for home care. Often cited as the future of health care by Republicans, MA was actually first enacted under the Clinton administration as “Medicare Plus Choice.”
Better Medicare Alliance President and CEO Allyson Y. Schwartz reminded people of that on Monday.
“The story of Medicare Advantage is one this new administration can be proud to continue,” Schwartz, a former member of the U.S. House of Representatives, said in a statement. “We stand ready to work with President-elect Biden, Vice President-elect Harris and their team to build on this bipartisan success.”
Out of a total Medicare-eligible population of more than 62.4 million individuals as of October 2020, nearly 25.4 million had signed up for MA, federal statistics show.
Biden, of course, has also voiced support for “Medicare at 60,” a plan to allow Americans between the ages of 60 and 64 the option of buying into Medicare slightly earlier. If ever enacted, that plan would dramatically expand the population of Medicare beneficiaries able to receive Medicare-certified home health services.
Lo que está en juego es si el gobierno federal desempeñará un papel más importante en el financiamiento y el establecimiento de las reglas básicas para la cobertura de atención médica o cederá más autoridad a los estados y al sector privado.
Si el presidente Donald Trump gana y los republicanos retienen el control del Senado, es posible que Trump aún no pueda hacer cambios radicales mientras la Cámara siga bajo control demócrata.
Pero, gracias a las reglas establecidas por los republicanos del Senado, se podrían seguir apilando demandas en los tribunales federales con juristas conservadores que probablemente defiendan el uso expansivo del poder ejecutivo por parte de Trump para tomar decisiones de salud.
El presidente también se ha comprometido a continuar sus esfuerzos para deshacerse de la Ley de Cuidado de Salud a Bajo Precio (ACA). Si la Corte Suprema anula la ley general como parte de un desafío que escuchará la próxima semana, se pondrá a prueba la promesa de los republicanos de proteger a las personas con condiciones médicas preexistentes.
En un segundo mandato, la administración probablemente también continuará sus esfuerzos para modificar Medicaid instituyendo requisitos laborales para los adultos inscritos y brindando más flexibilidad a los estados para cambiar el diseño del programa.
Si Joe Biden gana y los demócratas obtienen la mayoría en el Senado, sería la primera vez que el partido controla la Casa Blanca y ambas cámaras del Congreso desde 2010, el año en que se aprobó ACA.
Una de las principales prioridades será lidiar con la pandemia de COVID-19 y sus consecuencias económicas. Biden hizo de este tema una piedra angular de su campaña, prometiendo implementar políticas basadas en el asesoramiento médico y científico, y proporcionar más directrices y ayuda a los estados.
Pero también ocupa un lugar destacado en su agenda abordar partes de ACA que no han funcionado tan bien como esperaban sus autores. Se comprometió a agregar una “opción pública” administrada por el gobierno, que sería una alternativa a los planes de seguros privados en los mercados, y a reducir la edad de elegibilidad para Medicare a 60 años.
Si bien los demócratas continuarán controlando la Cámara, aún no se ha determinado la composición final del Senado. E incluso si los demócratas ganan el Senado, no se espera que obtengan una mayoría que les permita aprobar leyes sin el apoyo de algunos senadores republicanos, a menos que cambien las reglas del Senado.
Pero quién controle Washington es solo una parte del impacto de las elecciones en las políticas de salud. Varios problemas de salud clave están en manos de los estados. Algunos de ellos:
En Colorado, una medida que habría prohibido los abortos después de las 22 semanas de embarazo, excepto para salvar la vida de la embarazada, fracasó, según The Associated Press. Colorado es uno de los siete estados que no prohíben los abortos en algún momento del embarazo.
También alberga una de las pocas clínicas del país que realizan abortos en el tercer trimestre del embarazo, a menudo por complicaciones médicas graves. La clínica atrae pacientes de todo el país, por lo que los residentes de otros estados se habrían visto afectados si se aprobara la enmienda de Colorado.
En Louisiana, sin embargo, los votantes aprobaron fácilmente una enmienda a la constitución estatal para indicar que nada en el documento proteja el derecho al aborto o a financiarlo. Esto facilitaría que el estado prohíba el aborto si la Corte Suprema anula Roe v. Wade, que hace que las prohibiciones estatales del aborto sean inconstitucionales.
El destino del programa de salud para las personas de bajos ingresos no está en la boleta electoral directamente en ninguna parte de esta elección. (Los votantes aprobaron expansiones del programa en Missouri y Oklahoma a principios de este año).
Pero el programa se verá afectado no solo por quién controle la presidencia y el Congreso, sino también por quién controle las legislaturas en los estados que no han expandido Medicaid en el marco de ACA. Carolina del Norte es un estado clave donde un cambio en la mayoría de la legislatura podría modificar el rumbo de la expansión.
Marihuana y alucinógenos
En seis estados, los votantes están decidiendo la legalidad de la marihuana de una forma u otra. Montana, Arizona y Nueva Jersey estaban decidiendo si unirse a los 11 estados que permiten su uso recreativo.
Los votantes de Mississippi y Nebraska estaban eligiendo si legalizarían la marihuana medicinal, y Dakota del Sur se convirtió en el primer estado en votar sobre la legalización de la marihuana medicinal y recreativa en la misma elección.
Las setas alucinógenas (hongos) están en dos papeletas. Se aprobó una medida en Oregon para permitir el uso de hongos productores de psilocibina con fines medicinales, y una propuesta del Distrito de Columbia para despenalizar los hongos alucinógenos estaba ganando adeptos.
También se aprobó una pregunta en la boleta electoral en Oregon para despenalizar la posesión de pequeñas cantidades de drogas duras, incluida la heroína, cocaína y metanfetamina, y ordenar el establecimiento de centros de recuperación de adicciones, utilizando parte de los ingresos fiscales de las ventas de marihuana para establecer esos centros.
Como de costumbre, los votantes de California se enfrentaron a una larga lista de medidas electorales relacionadas con la salud.
Por segunda vez en dos años, la rentable industria de diálisis renal del estado fue cuestionada en las urnas. Una iniciativa patrocinada por un sindicato habría requerido que las empresas de diálisis contrataran a un médico en cada clínica y presentaran informes sobre casos de infecciones al estado. Pero la industria gastó $105 millones en contra de la medida. La medida falló, según AP.
También se les pidió a los votantes que decidieran, nuevamente, si financiarían la investigación con células madre del Instituto de Medicina Regenerativa de California a través de la Proposición 14. Los votantes aprobaron por primera vez el financiamiento para la agencia en 2004 y, desde entonces, se han gastado miles de millones con pocos resultados que derivaran en curas. La medida estaba ganando en los primeros resultados.
California ha estado a la vanguardia de la lucha por la llamada economía de los gig, y la votación de este año incluyó una propuesta impulsada por empresas de transporte como Uber y Lyft que les permitiría seguir tratando a los conductores como contratistas independientes en lugar de empleados.
Según la Proposición 22, las empresas no tendrían que proporcionar beneficios de salud directos a los conductores, pero tendrían que darles a los que califiquen un estipendio que podrían utilizar para pagar las primas de seguro médico comprado en el mercado del estado, Covered California. La medida fue aprobada.
Finalmente, se preguntó a los votantes si imponer impuestos a la propiedad más altos a los dueños de propiedades comerciales con terrenos y tenencias de propiedades valoradas en $3 millones o más, lo que podría ayudar a proporcionar nuevos ingresos destinados a ciudades y condados con problemas económicos afectados por el COVID-19, así como escuelas K-12 y colegios comunitarios.
Las clínicas comunitarias, las enfermeras de California y Planned Parenthood se lanzaron a la espinosa batalla política por la Propuesta 15, enfrentándose a poderosos grupos empresariales, con la mira puesta en los ingresos para ayudar a reconstruir el empobrecido sistema de salud pública de California.
Los demócratas en California, que controlan todos los cargos electos en todo el estado y tienen una supermayoría en la legislatura, se han estado posicionando para una victoria de Biden, y algunos ya estaban redactando una ambiciosa legislación de atención médica para el próximo año.
Si gana Biden, dijeron que planean tomar medidas enérgicas contra la consolidación de hospitales y terminar con las facturas sorpresa de las salas de emergencias, y algunos estaban discutiendo en silencio iniciativas liberales como buscar un sistema de atención médica de pagador único y expandir Medicaid para cubrir a más inmigrantes sin papeles.
JoNel Aleccia, Rachel Bluth, Angela Hart, Matt Volz y Samantha Young colaboraron con esta historia.
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These differences in Medicaid payments arise from two sources of policy variation. First, states differ in their adoption of so-called “lesser-of” policies, which are provisions for Medicaid to pay the lower of (a) Medicare’s cost sharing, or (b) the difference between the Medicaid fee schedule and Medicare’s payment for a service (net of cost sharing).1 Second, Medicaid fee schedules, which vary across states and over time, affect the amount of cost sharing that Medicaid will pay providers in lesser-of states.
In lesser-of states with low Medicaid fee schedules, providers can be paid substantially less when rendering services to duals vs other Medicare beneficiaries, who either pay Medicare’s cost sharing out of pocket or have private supplemental (ie, Medigap) insurance to
cover these expenses.
Unsurprisingly, providers are not as excited to provide care for dual-eligibles when they get paid less money for providing the same services they provide to Medicare beneficiaries (see Mitchell et al 2004, Haber et al. 2014, Zheng et al. 2017).
To measure variation in state Medicaid policies regarding dual eligibles, a paper by Roberts et al. (2020) describes the process of creating a database of these policies. The sources of the database were (i) state Medicaid plans and amendments filed with CMS; (ii) state laws from LexisNexis; (iii) and Medicaid provider manuals, program bulletins, and related online policy documents. Then the authors created a payment index using a nationally representative sample of claims data for evaluation and management services HCPCS codes. The database is publicly available here.
Based on these data, the share of states with <80% coverage of Medicare coinsurance and deductibles has grown over time, from 24 states in 2004 to 29 states in 2018. Further, the number of states that provide full reimbursement fell from 11 in 2004 to 7 in 2018.
One limitation of the data used for this evaluation is that it ignores managed care. Medicaid managed care organizations (MCOs) and MCOs are have grown–relative to Medicaid fee-for-service–over time.
Lesser-of policies function similarly under Medicaid managed care, except that Medicaid MCOs pay the lesser-of (a) the difference between their negotiated provider rates and Medicare’s payment amount, and (b) Medicare’s cost sharing. However, to the extent payment rates negotiated by Medicaid MCOs differ from those in fee-for-service Medicaid, our payment index will not accurately reflect provider payments for duals enrolled in Medicaid MCOs.
Further, the analysis also does not include Medicare Advantage beneficiaries. In 2018, Medicare Advantage plans covered 33% of dual-eligibles with full Medicaid.
Nevertheless, the creation of this dataset to track changes in Medicaid dual-eligible generosity is certainly a useful contribution to the literature.
- Roberts ET, Nimgaonkar A, Aarons J, Tomko H, Shartzer A, Zuckerman SB, Everette James A. New evidence of state variation in Medicaid payment policies for dual Medicare‐Medicaid enrollees. Health Services Research. 2020 Oct;55(5):701-9.
- Dataset: https://figshare.com/articles/New_Evidence_of_State_Variation_in_Medicaid_Payment_Policies_for_Dual_Medicare-Medicaid_Enrollees_Policy_Database_and_Index/12827390/1
If Republican President Donald Trump prevails, Democratic state lawmakers worry, they’ll be forced to scale back their ambitious plans and play defense the next four years, battling Republican attempts to curtail federal Medicaid spending and further unravel the Affordable Care Act.
Should Democratic presidential nominee Joe Biden win, California Democrats — who control all statewide elected offices and hold a supermajority in the legislature — are poised to go big on health care, pushing aggressively for a health care system that covers all Californians, regardless of their immigration status or ability to pay.
“This election will determine whether California has a willing federal partner who can move us forward in the ways we want to see health care expanded,” said Assembly member David Chiu (D-San Francisco).
“It is incredibly unlikely that another four years of Trump will allow us to make significant strides toward universal health care, whereas a Biden-Harris administration would allow us to make real progress toward not just health care for all, but so much more.”
California Dems Counting on Biden Win
Behind the scenes, Democrats in California are positioning for a White House led by Biden and vice presidential nominee Kamala Harris — which they presume would be more supportive of California’s agenda — and some are already planning legislation for next year. Not only are they plotting ways to crack down on hospital consolidation and end surprise emergency room bills, but they are also quietly discussing a trio of liberal initiatives that could again push California to the forefront of health care policy. They include:
- A new single-payer health care bill that would nix private insurance and create a taxpayer-funded health care system for all Californians. “Just expanding the Affordable Care Act is not nearly enough. We need to be willing to stand up to the drivers of health care costs rather than give Americans an insurance card that they can’t afford to use,” said Assembly member Ash Kalra (D-San Jose), who is considering introducing the measure. A legislative analysis in 2017 estimated that single-payer could cost California $400 billion a year.
- A wealth tax that could generate $7.5 billion a year to help finance potential coverage expansions. Assembly member Rob Bonta (D-Alameda) said wealthier people should pay more to help finance health care, education and other services, especially for Californians hit hard by the pandemic. “Some people have been offended and think that punishes the doers and innovators, but our intent is to help the most vulnerable,” he said.
- Expanding its Medicaid program for low-income residents, called Medi-Cal, to more unauthorized immigrants. California currently offers full Medi-Cal benefits to all qualified residents, regardless of immigration status, up to age 26. “To see Latinos in this state testing positive at disproportionate rates of COVID-19, it makes it clear that people are dying and suffering from lack of health coverage,” said state Sen. Maria Elena Durazo (D-Los Angeles), who plans to spearhead the proposal.
Democratic Gov. Gavin Newsom has argued that the future of health care, and California’s ability to combat COVID-19, is at stake this election.
Although Newsom has sought to play nice with Trump — partly because California relies on federal cooperation and federal money to respond to COVID-19 — the first-term governor strongly backs Biden.
“We can quite literally go backward with an administration that actively wants to get rid of health care for tens of millions of people with preexisting conditions,” Newsom said in September. But Biden, he said, will allow California to “accelerate our health care reforms and have a real partner that can advance those reforms to lower costs and improve quality, as well as expand access.”
The governor’s health care agenda includes far-reaching measures to expand access to care and set government-imposed limits on health care spending, possibly penalizing hospitals and doctors for failing to meet cost reduction targets. Though Newsom withdrew his biggest proposals earlier this year, citing a projected $54 billion state budget deficit, Health and Human Services Secretary Dr. Mark Ghaly said the administration is considering reintroducing proposals that died this year, including a new Office of Health Care Affordability.
But these plans could be jettisoned no matter who wins the election, warned Rose Kapolczynski, a California-based Democratic strategist. The state’s pandemic-crippled economy is likely to lead to more budget cuts, making it difficult to adopt new, expensive programs, she said.
“Everyone is going to be fighting for money, and it’s going to be hard to pass big-ticket expensive items like single-payer if California faces massive layoffs of state workers and cuts to health care programs that already exist,” she said.
A Trump Win Could Spur Health Care Innovation
While Democrats fear a rollback of health care funding and benefits should Trump win, his reelection could offer greater opportunity for Medicaid innovation in states, said Lanhee Chen, former adviser to 2012 Republican presidential nominee Mitt Romney and research fellow at Stanford University’s right-leaning Hoover Institution.
“States can be laboratories of innovation,” Chen said at an October presidential election forum at the UCLA Fielding School of Public Health.
In what is known as the waiver process, states can ask the federal government for permission to use federal dollars to offer services or pursue new approaches to health care that go beyond what Medicaid and Obamacare traditionally allow.
If reelected, Trump could help both red and blue states by giving them greater “freedom and flexibility” to undertake new programs, Chen said. The Trump administration has begun to embrace such experiments, including in Minnesota, where it approved a bipartisan effort to establish a reinsurance program that compensates insurers for taking on certain high-cost patients.
In Georgia, Republican Gov. Brian Kemp received permission from the administration to impose work requirements for Medicaid enrollees and require some to pay monthly premiums.
This process “is a way of both satisfying a conservative desire to enhance private marketplaces as well as a progressive desire to expand coverage,” Chen said.
Mark Peterson, a professor of public policy, political science and law at UCLA, is skeptical, saying the process has favored Republicans under Trump.
“The Trump administration has been trying to use Medicaid waivers to go in a more conservative direction, doing things such as allowing Medicaid work requirements,” he said.
The Newsom administration is seeking permission from the Trump administration to dramatically transform Medi-Cal to focus more on preventing enrollees from getting sick, and to invest in getting homeless people into housing and treatment. A COVID-spurred budget crisis forced Newsom to pause the $3.5 billion Medi-Cal overhaul earlier this year.
Newsom is also relying on federal cooperation to respond to COVID-19. The federal government, for example, allows California hospitals in hard-hit communities to relax minimum nursing staff levels.
To go as far as California wants on health care, “we do need the support and cooperation of the federal government — there’s no doubt,” Ghaly said in an interview with California Healthline.
But state Sen. Richard Pan (D-Sacramento) dismissed the idea that the Trump administration’s idea of innovation would help California Democrats, who are pursuing health policies Trump has attacked. “We’ve been hamstrung,” said Pan, who chairs the Senate Health Committee. “Trump has been president for four years and we haven’t seen it.”
The Affordable Care Act
One major issue doesn’t hinge on the presidential election but could nonetheless cast major doubt on Democrats’ big health care plans: the fate of the Affordable Care Act.
The U.S. Supreme Court will hear a case on Nov. 10 brought by Republican states, and backed by the Trump administration, that could invalidate Obamacare. California is leading the defense, and the state “stands to lose much of the historic gains it made,” said Melanie Fontes Rainer, a health care adviser to Attorney General Xavier Becerra.
Should the law be struck down, nearly 5 million Californians could lose health coverage, health insurance premiums could rise, and the state would likely have to make dramatic cuts to health and social safety net programs. Last year alone, the state received $25 billion to help fund its Affordable Care Act programs, according to Ben Johnson, a health care analyst at the nonpartisan Legislative Analyst’s Office.
California has also gone well beyond the requirements of Obamacare. It has expanded Medi-Cal to more people; imposed its own requirement to have insurance or pay a tax penalty after Congress eliminated the federal tax penalty; and offers state-financed premium subsidies for low- and middle-income Californians.
Yet state leaders have not identified a backup plan if Obamacare is struck down, and as they plot a far more aggressive agenda, they fear they would be forced to backtrack and struggle to protect what California has already done.
“We’ll be crippled and our gains would collapse,” Pan said. “We’d have to retrench entirely.”
This KHN story first published on California Healthline, a service of the California Health Care Foundation.
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These are just a few of the industry-shaping topics that home health insiders are following going into Election Day this Tuesday. While each presidential election is important, 2020 will help set the trajectory of U.S. health care policy for years to come.
No matter who wins between President Donald Trump and former Vice President Joe Biden, one thing is clear: In-home care gained a larger role in the overall continuum of care this year — and that momentum isn’t going away.
To get a deeper understanding of the 2020 election and what it means for home-based care operators, Home Health Care News reached out to several stakeholders for their perspective. Their responses are provided below, edited for length and clarity.
* * *
Regardless of who wins, the fundamentals for home health care remain the same. There is a growing need for more care and higher levels of care in the home. The pandemic has only accelerated this trend as family members eschew institutional care settings. Meanwhile, telemedicine and virtual care will play the dual role of supporting quality care in the home — particularly for patients who need fewer services — and blurring the lines of what is considered traditional home care.
As state Medicaid budgets tighten, care for dually eligible individuals who have chronic and long-term care needs will need to be addressed. These individuals account for 20% of Medicare and 15% of Medicaid enrollment, yet account for about a third of spending for each. In-home care and care management can play a critical role in improving outcomes while reducing the overall cost of care. However, the U.S. Centers for Medicare & Medicaid Services (CMS), Congress and state Medicaid programs will need to figure out the right models to integrate this care while figuring out who pays for what and who gets the savings.
Ensuring that home health agencies can fully participate in virtual care initiatives — including reimbursement for such services — and ensuring that dual eligible integrated care efforts fully value the impact of care in the home are two of our top priorities.
— Marki Flannery, president & CEO of the Visiting Nurse Service of New York (VNSNY)
* * *
The health care industry experienced unprecedented strains this year, but we also made strides in many areas. At the highest level, we saw bipartisan cooperation in the time of crisis that led to solutions for those acutely impacted by the pandemic, from telehealth coverage to Paycheck Protection Program (PPP) loans.
Regardless of the 2020 election outcome, in 2021, we’re turning our focus to a few key areas based on lessons learned from the public health emergency. Further elevating home health care as a viable care alternative is crucial. Whether it was helping to divert the surge on hospitals or sending patients home to recuperate from the effects of the virus in order to free up ICU beds, home care really rose to the occasion.
While there has been an increased appreciation and awareness of the power of home health care, there is still an opportunity to elevate understanding around the need for better home care reimbursement rates, fueled by an authentic understanding of the tireless value skilled and direct care workers provide. We are also working towards ways to secure and drive more competitive pay so that the home health care industry can more effectively fill the labor demand needed to support Americans who want to heal and thrive safely at home. We are continuing to see how cost-effective and truly preferred the home setting is for seniors who desire to age in place safely and securely. We want to do everything in our power to make this option more accessible.
— Jennifer Sheets, president & CEO, Interim HealthCare
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Regardless of the outcome of the election, the prospects for positive legislation impacting the home health sector in 2021 are promising. The new Congress will be interested in making policy changes to strengthen the Medicare program, examining the needs of the Medicare population and building off of lessons learned because of COVID-19. One of these lessons is that access to home health care for vulnerable populations can and should be optimized, particularly at times when the Medicare patient population is uniquely vulnerable. The home health community has developed policy solutions that offer Medicare beneficiaries a wider array of post-acute care options, including those that expand the availability of care at home.
Being able to “choose home” for more Medicare patients who need care, as an alternative to other institutional care, can not only ensure that high-quality clinical care is available to a wider Medicare population, but can also ensure safety and increased patient choice.
We have also seen that care in the home should be optimized through increased use of technology. The availability of telehealth should be expanded upon for Medicare home health patients, particularly in times when infection risk is high, as was the case during COVID-19. The Partnership believes that telehealth opportunities should be optimized to ensure continuity of care for our nation’s most vulnerable patients.
— Joanne Cunningham, executive director, Partnership for Quality Home Healthcare (PQHH)
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I’m hopeful that the current election will have a very positive impact on the home health industry going forward. That is because our industry has done a wonderful job over the years of advocating for our interests with a paramount emphasis on bipartisanship that is clearly evidenced in the recently introduced federal legislation calling for home health telehealth reimbursement during national emergencies.
In both the House and the Senate, these bills are being sponsored and supported by both Democrats and Republicans. That is extraordinarily significant. And coupled with the magnificent work our industry has done treating those in need during the current pandemic, the message has been communicated far and wide that our industry’s support spans the partisan political divide and is here to simply treat patients, clients and families with the health care services they need, when they need them, in the comfort, safety, security and familiarity of their homes.
— Dean Chalios, president & CEO, California Association for Health Services at Home (CAHSAH)
* * *
Home care and hospice have the advantage of being supported by both parties. As such, whatever the outcome of the election, we expect any health care reforms to embrace health care at home as the awareness of its value has grown significantly during the pandemic. Once the dust settles after the election, we are prepared to work with the incoming Congress and administration to further advance home care and hospice.
— William A. Dombi, president of the National Association for Home Care & Hospice (NAHC)
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The outcome of the 2020 presidential election could greatly impact legislation, support, attention and funding for home health care workers and agencies. Additionally, if the non-chronic illness Medicare-eligibility age is reduced to age 60 vs. 65, that will be a tremendous game-changer for payers, providers, patients and the entire health care ecosystem.
— Cleamon Moorer, Jr., president & CEO, American Advantage Home Care Inc.
The post Perspectives: Home Health Insiders Sound Off on the 2020 Election appeared first on Home Health Care News.
The Republican, who heads the Senate Judiciary Committee, attacked the law at the confirmation hearings for Supreme Court nominee Amy Coney Barrett. Democrats have made the nomination a referendum on the health law, which will be the subject of a Supreme Court hearing on Nov. 10. They fear the court may overturn the entire law, which has led to huge expansions in coverage and blocked insurers from discriminating against people with preexisting conditions, among other consumer protections.
Graham suggested that South Carolina was getting the short end of funding because the health law is sending a disproportionate amount of its money to states represented by Democrats in Congress.
“Under the Affordable Care Act, three states get 35% of the money, folks. Can you name them? I’ll help you: California, New York and Massachusetts. They’re 22% of the population. Sen. [Dianne] Feinstein’s from California, [House Speaker] Nancy Pelosi’s from California, Chuck Schumer, the leader of the Democratic Senate, is from New York, and Massachusetts is [Sen.] Elizabeth Warren. Now, why do they get 35% of the money when they’re only 22% of the population? That’s the way they designed the law: The more you spend, the more you get.”
His statement got us wondering if those numbers are true.
We asked Graham’s office for evidence to support his statement. His spokesperson responded with data he said was from the Centers for Medicare & Medicaid Services as well as the Medicaid and CHIP Payment and Access Commission, a congressional advisory board.
To look at total spending under the ACA, Graham’s office analyzed federal money that went to pay for the Medicaid expansion, tax credits given to consumers to subsidize premiums of insurance plans on the marketplace, cost sharing reduction subsidies (which were given to insurers to defray some of the costs they were required by the ACA to pick up for marketplace customers with very low incomes) and the Basic Health Program, which is an option in the ACA that lets states offer low-income residents different coverage than plans offered on the marketplaces.
Graham’s office did not share the actual reports used for the analysis, but staffers said they used 2016 data, even though more recent data was available. The numbers were based on calculations made in 2017 when Republican lawmakers sought to repeal and replace the ACA. Their analysis showed $118 billion in total 2016 federal spending on the ACA, with California, New York and Massachusetts receiving about $43 billion, or about 37% (slightly higher than what Graham cited at the hearing).
Nearly two-thirds of the funding was attributed to the expansion of Medicaid to all adults below the federal poverty level. The Supreme Court ruled that pursuing the expansion was an option left to states’ discretion — South Carolina opted against it. The federal government paid all those Medicaid costs from 2014 through 2016 for new enrollees and then gradually reduced its share to 90% today.
We decided to independently look at the spending using the latest available numbers. We reviewed federal data compiled by KFF as well as data provided directly from the U.S. Centers for Medicare & Medicaid Services and the states, when necessary. (KHN is an editorially independent program of KFF.)
It is important to note that the Trump administration ended the cost sharing reduction payments in October 2017. So, KHN’s analysis did not include spending for that program.
We analyzed the latest Medicaid expansion funding from 2018 and the latest Obamacare tax credit spending and also Basic Health Program spending from 2019. Only two states participate in that program, New York and Minnesota.
Adding up the latest data and the federal share of funding came to nearly $140 billion. Of that amount, New York, California and Massachusetts — which represent about 20% of the nation’s population — received a combined $40 billion, or about 29%.
The largest category of federal funding by far was the nearly $27.5 billion the three states together received from Medicaid expansion.
New York received about $5 billion in fiscal 2019 for the Basic Health Program.
Sifting through older datasets, one key discrepancy stands out in the figures used by Graham. He lists Massachusetts as receiving $6.1 billion in federal exchange subsidies — almost 20% of the national total — while federal data used by KFF in 2016 cites $360 million.
Graham insinuated that South Carolina wasn’t getting its fair share of money, calling the law “a disaster for the state.”
But the refusal by the state’s Republican leaders for the past seven years to expand Medicaid — which would have brought in billions of federal dollars — is the main reason for the funding disparity. South Carolina is one of 12 states that have not adopted Medicaid expansion.
That decision has left hundreds of thousands of the state’s residents uninsured because they have incomes too high for Medicaid but too low to qualify for federal subsidies to help them buy insurance plans sold on the ACA marketplaces. To qualify for a subsidy, consumers’ income must be at least at the federal poverty level, or $12,760 in 2020.
“A big driver of the flow of federal funds is related to that decision about whether to expand,” said Larry Levitt, KFF’s executive vice president for health policy. “It is not inherently in the design of the law.”
If South Carolina expanded Medicaid, about 330,000 more residents would be covered and the federal government would give an additional $1.6 billion in annual Medicaid funding to the state, according to an analysis by the Urban Institute. State Medicaid spending would rise by $250 million.
Even without expanding Medicaid, the uninsured rate in South Carolina has dropped from 20% in 2008 to about 13% in 2019, according to Census data.
More than 9 in 10 people in the state who get coverage through the ACA marketplace get tax credits to help them pay their monthly premiums.
In fact, South Carolina gets a larger share of those premium tax credits than most states. South Carolina, the nation’s 23rd-largest state by population size, ranks 11th in the number of residents getting those subsidies and ninth in receipt of the federal ACA premium subsidies, according to the federal data.
Disadvantage for ‘Fiscally Responsible States’
Kevin Bishop, a spokesperson for Graham, said the point of the senator’s remarks is that the ACA “is structured so that states that either expanded [Medicaid] or have favorable state eligibility will have a disproportionate share of funds. This gives an advantage to high-spending states.” States that are more “fiscally responsible” are at a disadvantage, he said.
Bishop acknowledged that ACA spending does change each year.
Levitt noted that Graham’s critique omitted an important perspective about other states. The senator did not mention that enrollees in two Republican-controlled states with large populations, Florida and Texas, receive more in ACA premium subsidies than people in New York or Massachusetts. However, neither of those Southern states has expanded its Medicaid program.
Still, experts noted that Graham’s comment that the more states spend the more they get from the ACA is partly true.
It accurately reflects the ACA’s Medicaid formula. As states expand Medicaid eligibility, they pick up more expenses and also receive more money in a federal match.
Joe Antos, a health economist with the conservative American Enterprise Institute, said Graham is correct that the Medicaid expansion was designed to help direct additional funding to wealthier states such as New York, California and Massachusetts. Those states, as well as some others, had broader Medicaid eligibility rules than poorer states before the law was enacted, so their Medicaid rolls were relatively larger already.
That’s why the Medicaid expansion was set at 138% of the federal poverty level, rather than 100%, he said. The higher amount meant those states could get a larger reimbursement for people already in their program.
But he said states that chose not to expand Medicaid under the law can’t blame the law for getting fewer federal dollars.
“If a state did not expand, it’s on them for having less federal funding,” Antos said.
Ed Haislmaier, a senior research fellow at the conservative Heritage Foundation, said the expansion of Medicaid for those more progressive states significantly increased their funding. “New York made out like a bandit,” he said, noting the state had one of the nation’s largest Medicaid populations before 2010.
Graham points to higher federal spending on ACA programs in three states that are represented by top congressional Democrats and complains that South Carolina is not faring as well. While his numbers are four years old, the latest numbers are just a few percentage points lower than what he cited — 29% compared with 35%.
He also left out some critical information — most important, that South Carolina didn’t pursue federal funding through Medicaid expansion.
His argument that the law was designed to help some states largely controlled by Democrats fails to note that many Republican-controlled states have received heavy federal funding, too, either because of ACA tax subsidies or Medicaid expansion, or both.
He also didn’t acknowledge that South Carolina does have a strong record of receiving federal subsidies for consumers buying insurance on the ACA marketplace.
We rate Graham’s statement as Half True.
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His administration supported repealing the Affordable Care Act’s Medicaid expansion, which has added millions of adults to the federal-state health program for lower-income Americans. He also wanted states to require certain enrollees to work. He sought to discontinue the open-ended federal funding that keeps pace with rising Medicaid enrollment and costs.
He has achieved none of these ambitious goals.
Although Congress and the courts blocked a Medicaid overhaul, the Trump administration has left its mark on the nation’s largest government-run health program as it has sought to make states more responsible for assessing its impact and improving the health of enrollees.
One notable achievement: The Trump administration pushed some states to be more aggressive in weeding out ineligible recipients — an initiative that led to a drop in enrollment of children in several states, including Missouri and Tennessee. About half of those enrolled in Medicaid are children.
A recent report from the Georgetown University Center for Children and Families found that the number of uninsured children rose by more than 700,000 to 4.4 million from 2017 through 2019. The increase of uncovered children stands out since uninsured rates typically drop during periods of economic growth, such as the one occurring from 2017 to 2019.
Advocates for the poor say the administration’s efforts contributed to an increase in the number of uninsured children, after years of decline. “The administration has not succeeded on any of its goals in any meaningful way,” said Joan Alker, executive director of the Georgetown center. “But they still have inflicted some damaging changes to the program.”
“The administration has not prioritized the health of children,” said Bruce Lesley, president of the child advocacy group First Focus on Children.
Alker attributes the rise in uninsured children to federal officials’ decision to slash outreach funding for the Obamacare insurance exchanges — through which families eligible for Medicaid are often identified — and the administration’s focus on the “public charge” rule. That provision allows the federal government to more easily deny permanent residency status, popularly known as green cards, or entry visas to applicants who use — or are deemed likely to use — publicly funded programs such as food stamps, housing assistance and Medicaid.
Medicaid officials said the increase is partly due to loss of health coverage by middle-income families who are not eligible for Medicaid. They say those families don’t qualify for government subsidies for the ACA’s marketplace plans and were forced to drop their plans because of high premiums.
But Alker said federal data suggests that families who have incomes over the 400% federal poverty level eligibility limit for subsidies (about $87,000 for a family of three) saw a slower rate of increase in the number of uninsured children as opposed to lower-income kids.
A spokesperson for the federal government’s Centers for Medicare & Medicaid Services said the agency was “committed to ensuring that eligible children are enrolled and retained in coverage” and it spent $48 million in grants for outreach and enrollment effort last year.
The Trump administration opposes the ACA’s expansion of Medicaid, which provided billions in federal dollars to cover nondisabled, low-income adults. Yet seven states adopted the expansion during the past three years, including Republican-controlled Utah, Idaho, Oklahoma, Nebraska and Missouri.
Despite the aim to shrink the program, about 75 million people were enrolled in Medicaid in June 2020 — roughly the same number as in January 2017, when Trump took office.
One reason is that Medicaid enrollment soared this year following the COVID-19 outbreak as unemployment spiked to historic highs and federal stimulus money forbid states to drop anyone unless they moved out of state.
But that is far from the administration’s goal of “ushering in a new day” for Medicaid, as CMS Administrator Seema Verma said when she laid out her bold vision in a 2017 speech.
Verma acknowledged she was stepping into a hornet’s nest of entrenched stakeholders and interest groups.
“I would like to invite everybody here today who have fought the political healthcare battles over the last decade to take a deep breath, exhale and agree to reset as a group,” she said.
They didn’t. The administration’s major Medicaid changes were met with opposition from hospitals, doctors and patient advocacy groups, who feared the efforts would lead to cuts in funding or add obstacles for enrollees seeking care.
Officials spent two years seeking to allow states to require enrollees to work or volunteer as a condition for enrollment. They approved proposals from 10 states, but only Arkansas implemented the new requirement before a federal judge ruled it illegal. Arkansas’ brief experience resulted in more than 18,000 adults losing coverage.
After losing in federal district and appeals courts, the Trump administration has appealed to the Supreme Court, which will decide later this year whether to take the case.
The push for work requirements and other changes have altered the culture of Medicaid so that officials are more intent on keeping people out of the program instead of welcoming more in, said Lesley, of First Focus.
Before the pandemic, he said, the administration allowed states to add hurdles for families to get enrolled and stay enrolled, such as requiring them to more frequently recertify their income eligibility.
Aaron Yelowitz, a professor of economics at the University of Kentucky, said one of the Trump administration’s biggest impacts on Medicaid was prodding states to be more active in making sure they were covering only people who met the states’ eligibility rules. He noted the ACA gave states incentives to enroll newly eligible adults over traditional groups such as children and the disabled because the federal government paid a higher share of the cost.
Seeking Flexibility for States
The administration — as well as Republicans in Congress — favored a fundamental change in how Medicaid is funded. But Congress failed to move the program to a “block grant” approach, which would have given states a set annual amount — rather than the current system that provides funding determined by how many people qualify for the program and health costs. The GOP proposal also would have allowed states more flexibility in running the operations.
Critics predicted a block grant would have cut billions in state funding and led to cuts in services and eligibility.
Once the legislative proposal was dead, the administration sought to enact the strategy via its authority to test changes in payment methods. Only one state applied — Oklahoma — and it dropped its application this year after voters passed a Medicaid expansion ballot initiative.
Verma promised to give states more flexibility in running their programs in other ways, while also holding them more accountable for care to Medicaid enrollees. CMS has approved dozens of Medicaid waivers since 2017, including allowing states to be more innovative in helping enrollees with substance abuse or addiction problems and serious mental illness. It granted more than 30 states waivers to enhance treatment options.
With Medicaid paying for more than half of all births in the United States, Verma also sought to improve oversight of prenatal and early childhood services.
While CMS has started a scorecard to track Medicaid outcomes, the data is missing for several states or outdated on several measures. For example, the low-birthweight measure is missing data from more than 20 states and no data is listed on children born with an addiction.
CMS officials said they are working to provide more updated information on its report card.
Changes implemented by the administration, officials added, have elicited more timely data from states, allowing them to spot problems quicker. For example, in September, CMS determined that many children were delayed from March through May in seeing a doctor and getting important vaccines as the pandemic took hold. CMS pushed states and health providers to remedy the problem but did not offer specific help.
Asked during a recent phone briefing with reporters about Medicaid’s legacy under her stewardship, Verma didn’t mention the expansion, work requirements or efforts to turn Medicaid into a block grant program for states.
“We have aimed to try to ensure the program is sustainable for generations to come and ensure better outcomes for those it serves,” she said.
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What You Should Know:
– Healthify in partnership with Algorex Health Technologies, announced the results of new social determinants of health (SDoH) population analysis of Excellus BlueCross BlueShield (BCBS) members.
– SDoH are non-clinical conditions that significantly
affect health outcomes. The analysis identified Excellus BCBS members who are
struggling with SDoH such as unstable housing, food insecurity and neighborhood
stress – which has enabled Excellus BCBS to develop a targeted SDoH strategy
focusing on members with the most need.
Healthify, a company that works with managed care organizations to integrate social determinants of health (SDoH) into the healthcare ecosystem, in partnership with Algorex Health Technologies, today announced the results of SDoH population analysis of Excellus BlueCross BlueShield (BCBS) members that identified high-risk members and the value of implementing SDoH initiatives. The data identified members who are struggling with unstable housing, food insecurity and neighborhood stress, which has enabled Excellus BCBS to develop a targeted SDoH strategy focusing on members with the most need.
Excellus BCBS turned to Healthify and
healthcare data analytics company Algorex Health to
provide deep analytic insights about how social determinants of health affect health quality
and cost. The SDoH data showed significant social needs
among members in Medicaid and other government sponsored programs and the value
of addressing the most prominent social determinants of health of
Healthify creates the infrastructure that drives
collaboration among community-based organizations, healthcare payers, providers
and policy makers to address social disparities with
aligned incentives and accountability. Healthify recently announced a
partnership with Algorex Health Technologies to expand its SDoH capabilities
to include SDoH predictive analytics that help health plan
and provider organizations better understand and proactively address the social needs
of vulnerable populations.
“SDoH analytics are critical for health plans that are implementing SDoH solutions,” said Manik Bhat, Founder and Chief Executive Officer of Healthify. “Analytics helps health plans build financial cases to solve for SDoH, prioritize highest-impact interventions in an accountable network and determine the right level of investment for SDoH initiatives.”
This will be ugly and sad. Racism has cost this country $16 trillion over the last twenty years according to a recent Citigroup report. Much of this loss ($13 trillion) was attributed to discriminatory lending practices and the 6.1 million fewer jobs created as a result, while disparity in wages ($2.7 trillion) and discrimination in housing policies and lost income due to restricted access to higher education accounted for the balance. The report estimates that if these gaps were to be closed, an incremental $5 trillion can be added to U.S. GDP over the next five years alone. Obviously, this does not even begin to account for the extraordinary pain and suffering racism inflicts on our country, much less the dramatic implications to the health and wellbeing for those impacted by racism.
The dramatic increase in unemployment since the onset of COVID-19 has garnered significant attention. While the overall unemployment rate of 7.9% in September is down from the pandemic-high of 14.7% in April, this improvement masks the dramatic discrepancies in rates for minorities; according to the U.S. Bureau of Labor Statistics, white Americans are 7.0% unemployed while the Black unemployment rate is 12.1%. Somewhat jarring, last week Columbia University published an analysis showing that eight million more people are now living in poverty just since the expiration of the Cares Act three months ago, disproportionally hitting minorities.
The story is even more dire when looking at the “True Rate of Unemployment” as defined by the Ludwig Institute for Shared Economic Prosperity which presumes that one needs to earn a minimum living wage of $20,000 to be deemed employed. Under such a definition, Black unemployment is 30.4%, although an improvement from what was seen for the ten years after the Great Recession of 2008.
It is estimated that 100.6 million Americans are out of the labor force now, many of whom are from disadvantaged segments of the population. In fact, for those earning more than $60,000 annually, the unemployment rate is a mere 1.0% below where it stood at the onset of the pandemic. For those who make less than $20 per hour (equivalent to a salary of approximately $27,000), the unemployment rate is 17.5% below where it was in February 2020 according to Opportunity Insights. Shockingly, America’s billionaires net worth has increased more than $850 billion since April.
The difference in life expectancy between white and Black Americans is criminally high – nearly five years, even when adjusted for gender, according to the Centers for Disease Control and Prevention (CDC) data. While the underlying causes are complex and fraught with political overtones, this issue is now front and center as the country struggles with the pandemic.
Sutter Health recently published COVID-19 data that attributed the 2.7x increase in hospitalization rates in their hospitals for Black patients versus white patients to, in part, more advanced illness at the time of admission, arguably reflecting a cultural aversion to the healthcare system or challenges around adequate access. CDC data are even worse, tabulating a 5.0x higher rate of hospitalization, 2.3x greater mortality rate, and 3.0x greater infection rate for Black versus white Americans, respectively. This is particularly troublesome now with case counts spiking 17% just this past week and as winter sets in.
The Kaiser Family Foundation (KFF) forecasts that Medicaid roles will increase by 8.4% in 2021; in June there were 67.9 million Medicaid beneficiaries. It is quite clear that the pandemic is hitting minority and less educated segments of the population harder, often because they tend to be front-line essential workers and/or struggle with greater levels of unemployment. McKinsey recently estimated that as many as 10 million Americans will lose employer-sponsored health insurance due to COVID-19 by the end of 2021.
KFF also highlights the discrepancies in private health insurance rates by race: in 2018, white, Black, and Hispanic uninsured rates were 7.5%, 11.5% and 19.0%, respectively, which further exacerbates difficulties for minorities to access effective healthcare. The Affordable Care Act had a dramatic impact over the past decade as uninsured rates in 2010 were 13.1%, 19. 9% and 32.6%, respectively. This year the average family health insurance premium rose by 4% to more than $21,000.
While there is a heightened level of concern about the pace of coronavirus vaccine development, and whether there will be inappropriate political pressures applied to compromise long-cherished safety protocols, the Black community is expressing a particularly high level of skepticism. According to another KFF study, just under 50% of Black respondents would not take a free and safe vaccine, while only 17% would “definitely” do so. While further underscoring long-held distrust of the healthcare system, this phenomenon risks perpetuating the relatively poor health conditions experienced in many of those communities.
Recognizing this and the other numerous challenges introduced by the pandemic, the Healthcare Anchor Network (HAN) of 39 provider systems (many of whom are Flare Capital LPs) reiterated in September that racism is a public health crisis, putting forth a number of steps to chip away at these issues. First and foremost was a commitment to dramatically improve access to testing in underserved communities, as well as more robust inclusive hiring practices and greater spending with diverse suppliers and vendors.
Importantly, the HAN spotlighted that systemic racism uncouples the public health infrastructure from the private healthcare system, often leading to “generational trauma and poverty.” A profound characterization. A recent Wall Street Journal analysis of CDC data showed a strong link between racism and mental health: in the week following the murder of George Floyd in May, 40.5% of Black adults exhibited symptoms of anxiety and depression (a five-point increase from the week just prior). While somewhat similar to post-traumatic stress disorders, racism is chronic and on-going much like an injury, and should not be considered a disorder. Clinicians have now developed a “Race-Based Traumatic Stress Symptom” scale when evaluating minority patients.
Advances in healthcare technology hold profound promise to improve the health and wellbeing of those most afflicted by racism, particularly during such difficult economic times. According to a provocative analysis by McKinsey (below), many of the most seminal transformative reforms in healthcare have come on the heels of major recessions. Arguably, what has been unleashed on the U.S. economy by COVID-19 may lead to a dramatic restructuring of the healthcare industry, which could usher in a wave of significant innovation to improve conditions for those most disadvantaged.
Entrepreneurship has been one of the great elixirs in the face of such devastating economic conditions and is often looked upon as one approach to reduce economic disparities due to racism. Here, unfortunately, the record is mixed. Given how critical access to capital is, the evidence that racial discrimination compromised many minority groups from accessing emergency funding programs like the Payroll Protection Program (PPP) this past spring is particularly painful. According to the Center for Responsible Lending, 46% of white-owned businesses had accessed bank credit over the past five years (compared to less than 25% for Black-owned businesses) which meaningfully facilitated their ability to secure PPP loans from those same institutions.
Furthermore, a 2016 Federal Reserve Bank study found that only 40% of minority credit applicants secure the full requested amounts of credit when applying as compared to 68% for white-owned applicants. Consistently minority-owned companies pay higher interest rates and have more onerous borrowing terms according to the Department of Commerce’s Minority Business Development Agency. The financial landscape confronting Black-owned businesses is materially more hostile than what white-owned businesses face. Full stop.
Rock Health, a leading seed-stage healthcare technology investor (and partner of Flare Capital), recently conducted an extensive diversity survey. These sober findings further highlight the issues around access to capital for minority entrepreneurs. White and Asian founders were nearly twice as likely to backed by venture capitalists; 48% of Black founders bootstrapped their companies versus 25% of white founders. Of the nearly 250 founder respondents in the survey, 12% identified as Black but only a disappointing 5% of the 425 senior executives in those companies were Black. Just over 80% of Black respondents felt that the digital health sector was either the same or less inclusive from when they initially joined the industry. Obviously, much work is still to be done.
These issues are not at all lost on my partners and our firm. Since we started Flare Capital over six years ago, we have been committed to diversity and inclusion. In addition to simply being the right thing to do, it is the best thing for our business. We will make better investment decisions with a broadly diverse set of perspectives and experiences.
But as inclusive as we felt we were, it is time to do even better. There are systemic causes to these inequities in our industry that we can help address. Over the last four months, we developed a set of new initiatives (summarized below) that we implemented earlier this summer. In summary, we identified two broad dimensions that we are committed to improving upon more equitable access and accelerated career development. Structural challenges exist for many underrepresented entrepreneurs to meet with venture capital firms, much less successfully raise capital. These are fundamental problems that require deliberate, measurable steps from engaging with more diverse founding teams, recruiting more diverse management teams, and partnering with venture firms equally committed to diversity.
BIPOC = Black, Indigenous, People of Color
We recognize that it will take time and significant effort to address these inequities, and that success will be built, in part, upon many small victories. Arguably, Black Lives Matter is the largest movement in our country’s history. The New York Times recently estimated that between 15 to 26 million Americans likely participated in demonstrations since the death of George Floyd in late May. We are proud to be a part of that movement.
About Michael A. Greely
Michael A. Greely is the CoFounder and General Partner at Flare Capital Partners, a venture capital firm focused on investing in early-stage and emerging healthcare technology companies. Previously, Michael was the founding General Partner of Flybridge Capital Partners where he led the firm’s healthcare investments. Current and prior board seats include Aspen Health, BlueTarp Financial, Circulation, Explorys, Functional Neuromodulation, HealthVerity, higi, Iora Health, MicroCHIPS, Nuvesse, PolyRemedy, Predictive Biosciences, Predilytics, T2 Biosystems, TARIS Biomedical, VidSys and Welltok (observer).
No private firms bid on Florida’s $30 million contract to set up and operate a drug importation program. Bids were due at the end of September.
The setback is likely to delay by at least several months Florida’s effort to become the first state to import drugs.
A spokesperson for the Florida Agency for Health Care Administration said the state is exploring its options. “The agency remains confident it will find a qualified vendor soon,” the spokesperson said. The state had planned to award a contract to a private vendor in December.
The disclosure of no bidders comes less than a month after the Trump administration cleared the way for states to apply for federal permission to set up an importation program — reversing nearly two decades of U.S. policy.
A 2003 law allows drug importation from Canada, but only if the head of the federal Department of Health and Human Services deems it safe and cost-effective. HHS Secretary Alex Azar made that declaration Sept. 24 and approved final rules for such initiatives.
Jane Horvath, a health consultant in College Park, Maryland, said potential bidders on the Florida contract were likely put off because the final federal rules were not set until late September. And private firms didn’t want to bid on a contract that would have to change if the Florida rules conflicted with those from Washington, she said.
Several inconsistencies are apparent between the Florida plan and what is allowed under the HHS final rules, she said. For example, Florida aims to give bonus-scoring points to contractors that repackage and relabel drugs in Florida, which is not allowed under the federal rules.
Another problem is that the private contractor has to determine which prescription drugs will produce the most savings for Florida’s Medicaid program, which is difficult since Medicaid rebates and other discount pricing are confidential.
“It could be that the $30 million contract is not enough either,” Horvath said.
Drug prices are lower in Canada because the country limits how much drugmakers can charge for medicines. The United States lets drugmakers and their distributors dictate prices.
Trump, who made lowering prescription drug prices a key campaign issue in 2016, has promoted importation, especially in messages geared to seniors during his reelection bid.
Critics say importing drugs from Canada would threaten the drug supply with counterfeit products. Because high-cost biologic drugs, including insulin, and intravenously injected medicines are not allowed to be imported under current law, the strategy could have limited impact.
Even with HHS backing, drug importation faces several challenges. Most notably, Canada has vowed to stop any effort that would exacerbate drug shortages there, which could make it challenging to identify a Canadian exporter. And the pharmaceutical industry opposes the program and is likely to sue to stop it.
Florida plans to set up an importation program to help lower drug prices for people covered by state programs such as Medicaid and the Corrections Department. The state has projected savings of up to $150 million a year.
The federal rules take effect Nov. 30, which is when states can formally apply to HHS to set up their program.
A chief architect of Florida’s importation plan, Mary Mayhew, who was secretary of the Florida Agency for Health Care Administration, resigned in September to become CEO of the Florida Hospital Association.
Mayhew refused to comment for this story.
Vermont, Colorado, Maine, New Hampshire and New Mexico are also devising programs to import drugs from Canada.
Colorado officials plan to seek out private contractors for that state’s program in 2021, and they hope to get final federal approval by summer 2022, officials said during a recent call with stakeholder groups.
Colorado plans to allow consumers to get drugs from Canada at their U.S. pharmacy or through mail order. It estimates residents could save an average of 61% off the price of medicines in Colorado today.
It’s unclear what impact the outcome of the presidential election will have on drug importation. Democratic nominee Joe Biden said he supports importing drugs from Canada. But, if elected, he is also likely to review many of the Trump administration’s actions.
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The Centers for Medicare and Medicaid Innovation (CMMI) created the Direct Contracting Model to expand opportunities for more diverse providers and healthcare organizations to participate in value-based care arrangements for Medicare fee-for-service (FFS) beneficiaries.
The goal of the new model is to create the next generation of risk-sharing arrangements to improve outcomes for patients, lower costs, and ensure high-quality care. In developing the Direct Contracting model and associated payment options, CMMI decided to build on lessons learned from accountable care initiatives, in particular, the Next-Generation ACO (NGACO) Model, as well as Medicare Advantage and other innovative private payers. The new model specifically aims to attract providers new to Medicare FFS and Innovation Center models: “the payment model options appeal to a broad range of physician practices and other organizations because they are expected to reduce burden, support a focus on beneficiaries with complex, chronic conditions, and encourage participation from organizations that have not typically participated in Medicare FFS or CMS Innovation Center models.”
High risk equals high reward for the new Direct Contracting Entities (DCE). The payment model options that participants can choose from aim to (1) increase risk-sharing arrangements through capitated and partially capitated population-based payments, (2) include providers and organization new to Medicare FFS, (3) increase access and empower beneficiaries in their care, and (4) decrease provider burden by emphasizing only core quality metrics and making certain care delivery waivers available. Importantly, the model offers options for new entrant DCEs, meaning DCEs that have no or limited experience with Medicare FFS beneficiaries and associated Medicare risk-based contracts, as well as high needs DCEs that will focus specifically on high cost, high acuity beneficiaries.
The Direct Contracting model begins with an optional six-month implementation period on October 1, 2020, which is intended to support organizations that need additional time to align beneficiaries and optimize their care coordination and management functions. In light of COVID-19’s overwhelming impact on healthcare this year, CMMI announced the first Direct Contracting Model performance year will start April 1, 2021—a three-month delay from the original start date, with five performance years to follow. The second cohort of Direct Contracting participants will begin in January 2022.
The Innovation Center will initially test two risk-sharing options:
- Professional – includes a 50% shared savings/shared losses provisions and Primary Care Capitation, a capitated, risk-adjusted monthly payment for enhanced primary care services that’s equal to seven percent of the total cost of care benchmark for enhanced primary care services
- Global – is 100% full risk option with either Primary Care Capitation or Total Care Capitation, which is a capitated, risk-adjusted monthly payment for all services provided by Direct Contracting Participants and preferred providers.
CMS may test a third option, the Geographic Option, in the future, which would also be a 100% risk arrangement offering an opportunity for participants to assume the total cost of care risk for Medicare FFS beneficiaries in a defined region.
Achieving Success in the Direct Contracting Model:
Similar to existing accountable care models, critical elements to achieve success in the Direct Contracting model include a focus on workflows, systems, and partnerships that support care coordination activities, including connections to needed healthcare and wrap-around services, as well as supporting providers in attaining quality benchmarks while managing overall utilization. Underlying these capabilities is access to real-time actionable information to drive timely interventions and coordination activities.
Real-time information through admission, discharge, and transfer (ADT) event notifications for Emergency Department, hospital, or post-acute encounters enable care coordination teams to deploy workflows and resources to more easily and quickly support patients. Knowing when and where patients are receiving care and understanding the clinical context for their care allows providers and care teams to more seamlessly work together to provide the right care at the right time without unnecessary or duplicative interventions. It also allows care teams to identify patients at high risk for complications, including readmissions and can prompt time-sensitive outreach and connection to additional resources.
Having access to real-time information can not only improve patient outcomes and quality but will also help to maximize payment incentives for Direct Contracting participants. Coordinated care consistently leads to shorter lengths of stay, which not only has positive quality implications for patients but also financial benefits for Direct Contracting Entities.
In addition, healthcare organizations can use real-time information to continuously strengthen and refine care network partnerships and collaborations.
To effectively manage Medicare FFS patients within the Direct Contracting Model, participants will need to coordinate with other providers across care settings and deploy timely interventions that support patients’ health and well-being. Real-time information, through ADT data, will provide participants with a new level of clinical intelligence to successfully prioritize and deploy care coordination services and ensure seamless transitions of care for patients while also creating optimal opportunities to achieve shared savings.
About Vanessa Kuhn, Ph.D
Vanessa Kuhn, Ph.D., is the Director of Policy at PatientPing, a care collaboration platform that provides real-time visibility into patient care events across the continuum. PatinetPing works with hospitals, post-acutes, health plans, ACO’s and beyond, the platform connects providers across the nation to improve patient and organizational outcomes.
What You Should Know:
– Unite Us, the tech company building coordinated care
networks nationwide announced a significant expansion to its partnership with
Nebraska Health Information Initiative (NEHII), a health information exchange,
to six additional states.
– This growing partnership aims to break down existing obstacles between
clinical and social service providers to allow for improved SDoH workflows, comprehensive,
whole-person care with trackable outcomes and data, and the creation of
sustainable long-term models for care.
Unite Us, the technology
company building coordinated care networks nationwide, announced today that it
is expanding its partnership with Nebraska Health
Information Initiative (NEHII), a Health Information Exchange (HIE), to six
additional states including Iowa, Missouri, South Dakota, North Dakota, Kansas,
and Minnesota. This growing partnership aims to break down existing obstacles
between clinical and social service providers to allow for comprehensive,
whole-person care with trackable outcomes and data.
This expansion between Unite Us and NEHII comes on the heels
of Unite Nebraska, the pair’s first joint statewide network that was announced
in June 2020 and launched last month, and will allow more people in need across
the country to get the services they need. Unite Us and NEHII have begun
rolling out the partnership into the additional states, and all networks will
be live by August 2022.
Why It Matters
Beyond the clinical care a person receives, 80% of an
individual’s health and quality of life is affected by their social
determinants of health (SDoH), conditions in the environment where people
are born, live, work, play, and worship.* It is critical that health care
providers have access to this full picture of their patients’ lives beyond the
clinic and hospital walls, in order to identify and help eliminate potential
barriers to their health and well-being.
NEHII is committed to helping organizations addressing SDoH
improve their workflows, track results and metrics, avoid wasteful and repeated
care, and create sustainable long-term models for care. NEHII will utilize
Unite Us’ person-centric platform to provide transparency, accountability, and
outcomes data to providers, and to incorporate community-based social care into
state ecosystems, particularly in rural areas with geographic variations in
access to critical services. This expansion and continued partnership paves the
way for additional collaborations with other HIEs, multiple health systems and
state Medicaid departments as they collectively move towards systems change.
“NEHII is thrilled to be expanding our partnership with Unite Us into six new states, to enable better support and health outcomes for all Americans,” says Jaime Bland, President and CEO of NEHII. “We know patients don’t seek care in a single institution, let alone a single state, especially along our borders. Statewide infrastructures for health and social care are more crucial than ever as COVID-19 continues to devastate the nation. We’re eager to help additional states combine their clinical and social care data in one secure location to provide patients and providers a more comprehensive view of their longitudinal health record.”
For the first time in a long time, there is some good news about the coronavirus pandemic: Although cases continue to climb, fewer people seem to be dying. And there are fewer cases than expected among younger pupils in schools with in-person learning. But the bad news continues as well — including a push for “herd immunity” that could result in the deaths of millions of Americans.
Meanwhile, the Trump administration is doubling down on efforts to allow states to require certain people with low incomes to prove they work, go to school or perform community service in order to keep their Medicaid health benefits. The administration is appealing a federal appeals court ruling to the Supreme Court and just granted Georgia the right to impose a work requirement.
This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Paige Winfield Cunningham of The Washington Post and Alice Miranda Ollstein of Politico.
Among the takeaways from this week’s podcast:
- Opinions seem to be slowly shifting on opening schools around the country. As fall approached, many people were hesitant to send their children back to school because they feared a resurgence of coronavirus infections, but early experiences seem to show that there has been little transmission among young kids in classrooms.
- Even with good results in those school districts that have reopened, however, the debate about whether schools should be conducting in-person learning is quite polarized. President Donald Trump repeatedly calls for all schools to resume, while groups, such as unions representing teachers and other employees, are more likely to be calling for continued online learning.
- California, which had a strong resurgence of the virus during the summer, is seeing signs of success in fighting back. The state has been among the most aggressive in shutting down normal activities to reduce case levels. It devised a county-specific method to determine closures, restrictions and reopenings — and it appears to be working.
- A proposal by some researchers to move the country toward a “herd immunity” plan, in which officials would expect the virus to spread among the general population while also trying to protect the most vulnerable — such as people living in nursing homes — is gaining support among some of Trump’s advisers. Public health advocates are raising alarms because it would likely lead to hundreds of thousands more deaths. They also fear the administration’s focus on restoring normalcy would by default move in this direction.
- Federal researchers this week announced that nearly 300,000 excess deaths have been recorded this year and much of it is attributed to COVID-19 or the lack of other health care by people who could not or did not seek treatments because they were frightened by the pandemic.
- With the Senate poised to confirm Amy Coney Barrett, who opposes abortion, to the Supreme Court within days, the fate of the landmark Roe v. Wade decision is in question. If the court overruled that decision, abortion policies would likely fall back to individual states. A recent report on the effects of such a scenario finds that a huge swath of the South and the Midwest would be left without a local facility offering abortion services.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:
Julie Rovner: Cook’s Illustrated’s “The Best Reusable Face Masks,” by Riddley Gemperlein-Schirm, and The Washington Post’s “Consumer Masks Could Soon Come With Labels Saying How Well They Work,” by Yeganeh Torbati and Jessica Contrera
Margot Sanger-Katz: The Hill’s “Republicans: Supreme Court Won’t Toss ObamaCare,” by Peter Sullivan
Paige Winfield Cunningham: The Wall Street Journal’s “Some California Hospitals Refused Covid-19 Transfers for Financial Reasons, State Emails Show,” by Melanie Evans, Alexandra Berzon and Daniela Hernandez
Alice Miranda Ollstein: ProPublica’s “Inside the Fall of the CDC,” by James Bandler, Patricia Callahan, Sebastian Rotella and Kirsten Berg
To hear all our podcasts, click here.
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A Massachusetts-based home health company and its owners will pay millions of dollars to resolve allegations that they falsely billed the state’s Medicaid program, MassHealth.
The home health company is Altranais Home Care LLC, located in Lowell. Massachusetts Attorney General Maura Healey announced Friday that the company and owners Constant Ogutt and Shakira Lubega will pay a total of $3.1 million to resolve allegations associated with the medical necessity of services dating back to 2014.
Specifically, allegations claimed that Altranais Home Care submitted false claims to MassHealth and MassHealth’s managed care entities for home health services not appropriately authorized by a physician. The provider did so “knowingly” or “in reckless disregard of billing requirements,” according to the attorney general.
“Home health companies have an obligation to provide only those services that are medically necessary,” Healey said in a statement. “This company allegedly defrauded MassHealth and improperly used scarce resources for services that were not deemed necessary by a physician.”
The settlement is part of a broader home health enforcement effort in Massachusetts to combat fraud, waste and abuse.
In April 2019, Avenue and Amigos Home Care paid a combined $10 million to resolve allegations of similar false billing. In August 2019, Guardian Healthcare paid $1.95 million to resolve similar allegations, too.
As part of its business mix, Altranais Home Care provides skilled nursing, therapy and social services. The company’s founders — both nurses — opened their first location in Tewksbury, Massachusetts, before expanding throughout the east, central and western portions of the state.
Financial settlements to resolve allegations associated with the medical necessity of services are not uncommon in the industry. Such settlements are also not an admission of guilt by the provider.
Apart from its financial settlement, Altranais Home Care will be mandated to operate under a multi-year independent compliance program, according to the Massachusetts attorney general.
The program will be implemented by “an independent compliance monitor.” It will require the company to establish updated policies and procedures ensuring compliance with federal and state laws. It will also require the provider to conduct annual training for all employees and perform annual audits, the results of which will be reported to the attorney general’s office.
“Today’s outcome is the result of MassHealth’s strong program integrity efforts to prevent fraudulent billing, and demonstrates the ongoing relationship between MassHealth and the Medicaid Fraud Division,” Dan Tsai, assistant secretary for MassHealth and the Massachusetts Medicaid director, said in a statement.
The post Home Health Provider to Pay $3.1M to Resolve Improper Billing Allegations appeared first on Home Health Care News.
In comments recently submitted to the administration, PhRMA raised concerns with a number of changes included in the Centers for Medicare & Medicaid Services (CMS) Medicaid proposed rule. Today, we’re diving deeper into CMS’s proposal to vastly expand the types of medicines that would fall under the definition of a “line extension” and how that change threatens future development of needed cures and treatments by establishing a tax on innovation.
What You Should Know:
– Innovaccer unveils new risk adjustment solution to help providers better segment their population to refine the risk scoring process and improve coding accuracy and efficiency, thereby improving performance on risk-based contracts.
– The solution utilizes Artificial Intelligence (AI) and
Natural Language Processing (NLP) to make risk predictions.
Innovaccer, Inc., a
technology company, has launched its Risk Adjustment
Solution. Leveraging Innovaccer’s industry-leading, FHIR-enabled Data
Activation Platform, providers can better segment their population to refine
the risk scoring process and improve coding accuracy and efficiency, thereby
improving performance on risk-based contracts. The solution utilizes Artificial Intelligence
(AI) and Natural Language Processing (NLP) to make risk predictions. By
improving care management workflows, Innovaccer works to help all members of
the health team care as one.
Addressing End-to-End Risk Adjustment
Innovaccer’s solution is designed to address end-to-end risk
adjustment needs by allowing providers to use actionable insights on dropped
codes and suspected codes across various risk models. The solution works with
the Centers of Medicare & Medicaid hierarchical condition categories
(CMS-HCC), Department of Health and Human Services hierarchical condition
categories (HHS-HCC), and the Chronic Illness and Disability Payment System
(CDPS), helping providers improve coding accuracy.
Segment Patient Population Based on Risk Scores
Providers can identify codes that can be integrated into the
EHR using simple
steps through advanced risk adjustment analytics. Innovaccer’s platform can
also segment the patient population based on risk scores available through
historical data and provide dashboards to identify details related to Risk
Adjustment Factor (RAF) and risk capture trends. Providing curated insights to
risk coders prevents them from having to switch between multiple screens,
reducing the time spent on coding processes.
“Innovaccer’s Risk Adjustment Solution caters to all risk management needs through one seamless platform. It is AI and NLP ready, and by leveraging the platform’s smarter workflows and actionable insights, providers can decrease time spent on risk-related coding by up to 40%. The solution helps providers to refine the risk scoring process and improve coding accuracy and efficiency for improved performance on risk-based contracts,” says Abhinav Shashank, CEO at Innovaccer.
The Affordable Care Act, facing its first test during a deep recession, is providing a refuge for some — but by no means all — people who have lost health coverage as the economy has been battered by the coronavirus pandemic.
New studies, from both federal and private research groups, generally indicate that when the country marked precipitous job losses from March to May — with more than 25 million people forced out of work — the loss of health insurance was less dramatic.
That’s partly because large numbers of mostly low-income workers who lost employment during the crisis were in jobs that already did not provide health insurance. It helped that many employers chose to leave furloughed and temporarily laid-off workers on the company insurance plan.
And others who lost health benefits along with their job immediately sought alternatives, such as coverage through a spouse’s or parent’s job, Medicaid or plans offered on the state-based ACA marketplaces.
From June to September, however, things weren’t as rosy. Even as the unemployment rate declined from 14.7% in April to 8.4% in August, many temporary job losses became permanent, some people who found a new job didn’t get one that came with health insurance, and others just couldn’t afford coverage.
The upshot, studies indicate, is that even with the new options and expanded safety net created by the ACA, by the end of summer a record number of people were poised to become newly uninsured.
What’s more, those losses could deepen in the months ahead, and into 2021, if the economy doesn’t improve and Congress offers no further assistance, health policy experts and insurers say.
“It’s a very fluid situation,” said Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, a New York-based health research group. “The ACA provides an important cushion, but we don’t know how much of one yet, since this is first real test of the law as a safety net in a serious recession.”
Collins also noted that accurately tracking health insurance coverage and shifts is difficult in the best of times; amid an economic meltdown, it becomes even more precarious.
Coverage Was Already on the Decline
Some 20 million people gained coverage between 2010 and 2016 under the ACA’s expansion of Medicaid and its insurance marketplaces for people without employer-based coverage. A gradually booming economy after the 2008-2009 recession also helped. The percentage of the population without health insurance declined from about 15% in 2010 to 8.8% in 2016.
But then, even as the economy continued to grow after 2016, coverage began to decline when the Trump administration and some Republican-led states took steps that undermined the law’s main aim: to expand coverage.
In 2018, 1.9 million people joined the ranks of the uninsured, and the Census Bureau reported earlier this month that an additional 1 million Americans lost coverage in 2019.
The accelerating decline is helping fuel anxiety over the fate of the ACA in the wake of the death of Supreme Court Justice Ruth Bader Ginsburg. The high court is scheduled to hear a case in November brought by Republican state officials, and supported by the Trump administration, that seeks to nullify the entire law.
In July, researchers at the Urban Institute, a Washington, D.C., think tank, forecast that around 10 million workers and their dependents would lose employer coverage in 2020. But they estimated that two-thirds of them will have found new coverage by year’s end — leaving about 3.3 million uninsured.
A more recent Urban Institute report, released Sept. 18, and using 2020 data from the Census Bureau, calculated that of the roughly 3 million people under age 65 who had lost job-based insurance between May and July, 1.4 million found coverage elsewhere — most through Medicaid — and 1.9 million became newly uninsured. Notably, 2.2 million of those who lost their coverage were between 18 and 39 years old; 1.6 million were Hispanic.
Another recent study, using different methods, reported higher numbers for the same period. The analysis released by the Economic Policy Institute last month determined that between April and July 6.2 million people lost employer coverage. The authors didn’t calculate how many found alternative coverage via Medicaid or the ACA, however.
Other findings support the notion that the health insurance loss trend shifted by mid summer. KFF, for example, published an analysis Sept. 11 showing that most companies that offered coverage to begin with chose to continue insuring furloughed and temporarily laid-off workers between March and the end of June. But as the virus continued to batter the economy, employers moved to permanently shed those jobs. (KHN is an editorially independent program of KFF.)
“The issue now is that the temporary layoffs have greatly decreased and permanent job losses, including jobs that came with health coverage, are increasing,” said Cynthia Cox, a KFF vice president and director for the Program on the ACA.
Many low-income workers who lose their jobs and don’t have coverage through a spouse or parent turn to Medicaid, the federal-state health program for low-income people. The Centers for Medicare & Medicaid Services reported last week that enrollment in Medicaid and the Children’s Health Insurance Program grew by 4 million between February and June, a nearly 6% increase since the beginning of the coronavirus crisis.
The Impact of the Marketplaces
Gains and losses of coverage in the ACA marketplace are not yet clear, experts say. The Trump administration issued a report in June indicating that 487,000 people had, between January and June, enrolled in an ACA plan via the federal website, healthcare.gov. But that report failed to say how many people dropped an ACA plan in that period — for example, because they could no longer afford the premiums.
A study by Avalere, a health research and consulting firm in Washington, D.C., has estimated that enrollment in the ACA marketplaces since March could have swelled by around 1 million. That includes new enrollees in the 13 ACA marketplaces that states, plus the District of Columbia, operate. Many of those states held a “special enrollment period” when the pandemic hit. Healthcare.gov, run by the Trump administration, did not offer a special enrollment period.
About 11 million were enrolled in an ACA plan in February. Open enrollment for coverage that would start on Jan. 1, 2021, begins Nov. 1.
Jessica Banthin, a senior health policy researcher at the Urban Institute and until 2019 deputy director for health at the Congressional Budget Office, said it’s anyone’s guess how many people who lost their job-based coverage this year will choose this option. She said numerous factors will influence people’s health insurance decisions this fall, and into 2021.
Chief among them is gauging whether they might soon get a new job, or get back an old job, that offers insurance. That may hold some people back from enrolling in an ACA plan this fall, Banthin said. Plus, buying insurance may be too expensive, especially for families more concerned with paying for housing, food and child care while going without a paycheck.
“Health insurance may not be their immediate concern,” Banthin said. “Many people’s lives have been disrupted as never before. There’s a lot of trauma out there.”
Collins of the Commonwealth Fund said that, even before the pandemic, a growing proportion of families were vulnerable to loss of coverage and care.
In a survey of more than 4,000 adults early this year, Collins and colleagues found a “persistent vulnerability among working-age adults in their ability to afford coverage and health care that could worsen if the economic downturn continues.”
In large part, that’s because 1 in 5 respondents who had coverage were “underinsured.” Underinsurance reflects the extent to which coverage leaves people at risk of high out-of-pocket costs — a situation exacerbated by widespread job loss.
“Now is absolutely not be the time for the ACA to be further undermined, let alone killed outright,” said Stan Dorn, director of the National Center for Coverage Innovation at Families USA.
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Living through a pandemic is stressful and anxiety-inducing. Stay-at-home measures are compounding this stress, resulting in social isolation and unprecedented economic hardship, including mass layoffs and loss of health coverage. Fully understanding the impact of these pernicious trends on overall mental health will take time. However, precedents like the Great Recession suggest that these trends are likely to worsen the conditions driving suicide and substance-related deaths, the “deaths of despair” that claimed 158,000 lives in 2017 and contributed to a three-year decline in US life expectancy among adults of all racial groups.
Even before the emergence and spread of COVID-19, the US was experiencing a behavioral health treatment crisis: 2018 data showed that only 43% of adults with mental health needs, 10% of individuals with SUD, and 7% of individuals with co-occurring conditions were able to receive services for all necessary conditions.
The treatment gap is staggering, and COVID-19 is exacerbating it: an estimated 45% of adults report the pandemic has negatively impacted their mental health, to say nothing of the disruption of essential in-person care and services. In a similar vein, a recent CDC report has highlighted the staggering and “disproportionately worse mental health outcomes, [including] increased substance use, and elevated suicidal ideation” experienced by “younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers.”
Consistent with the CDC report’s findings, the crisis can be felt most acutely by the very workforce that must deal with COVID-19 itself. Hospitals, health systems, and clinical practices – together with other first responders – comprise the essential front line. They bear the burden of their employees’ stress and illness, and must also cope with the many patients who present with a range of mental illnesses and substance use disorder (SUD).
But providers don’t have to face this burden alone: numerous behavioral health-focused digital solutions can support providers in meeting their most urgent needs in the era of COVID-19. Many of these solutions have made select services available for free or at a discount to healthcare providers in recognition of the immense need and challenging financial circumstances. Some solutions also help systems take advantage of favorable, albeit time-sensitive, conditions, enabling them to lay the foundation for broader behavioral health initiatives in the long term. Several of these solutions are described below, in the context of three key focus areas for health systems.
Focus Area 1: Supporting the Frontline Workforce
Health system leaders need to keep their workforces healthy, focused, and productive during this period of extreme stress, anxiety, and trauma. Providing easily accessible behavioral health resources for the healthcare workforce is therefore of paramount importance.
Health systems should consider providing immediate, free access to behavioral health services to employees and their families and consider further extending that access to first responders, other healthcare workers, and other essential services workers in the community.
Many digital product companies are granting temporary access to their services and are expanding their offerings to include new, COVID-19-specific modules, resources, and/or guidance at no cost.
Fortunately, the market is rife with solutions that have demonstrated effectiveness and an ability to scale. However, many of these rapidly-scalable solutions are oriented toward low-acuity behavioral health conditions, so it is important that health systems consider the unique needs of their populations in determining which solution(s) to adopt.
The following are several solutions to consider:
Online CBT solutions. These tools are being used to expand access to lower-acuity behavioral health services, targeting both frontline workers and the general population. MyStrength, SilverCloud and others have deployed COVID-19-specific programming.
Text-based peer support groups. Organizations are using Marigold Health to address loneliness and social isolation in group-based chat settings, one-on-one interactions between individuals and peer staff, and broader community applications.
Focus Area 2: Maintaining Continuity of Care
As the pandemic continues to ripple across the country, parts of the delivery system remain overwhelmingly focused on containing and treating COVID-19. This can and has led to the disruption of care and services, of particular significance to individuals with chronic conditions (e.g., serious mental illness (SMI) and SUD), who require longitudinal care and support. Standing up interventions — digital and otherwise — to ensure continuity of care will be critical to preventing exacerbations in patients’ conditions that could drive increased rates of ED visits and admissions at a time when hospital capacity can be in short supply.
In the absence of in-person care, many digital solutions are hosting virtual recovery meetings and providing access to virtual peer support groups. Additionally, shifts in federal and state policies are easing restrictions around critical services, including medication-assisted treatment (e.g., buprenorphine can now be prescribed via telephone), that can mitigate risky behavior and ensure ongoing access to treatment.
The use of paraprofessionals has also emerged as a promising extension of the historically undersupplied behavioral health treatment infrastructure. Capitalizing on the rapid expansion of virtual care, providers should consider leveraging digital solutions to scale programs that use peers, community health workers (CHWs), care managers, health coaches, and other paraprofessionals, to reduce inappropriate hospital utilization and ensure patients are navigated to the appropriate services.
The following are several solutions to consider:
Medication-assisted therapy (MAT) via telemedicine. These solutions provide access to professionals who can prescribe and administer MAT medications, provide addiction counseling, and conduct behavioral therapy (e.g., CBT, motivational interviewing) digitally. Solution companies providing these critical services include Eleanor Health, PursueCare, and Workit Health.
Behavioral health integration. Providing screening, therapy, and psychiatric consultations in a variety of care settings — especially primary care — will help address the increased demand. Historically, providers have had difficulty scaling such solutions due to challenging reimbursement, administrative burden, and stigma, among other concerns. Solutions like Valera Health and Concert Health were created to address these challenges and have seen success in scaling collaborative care programs.
Recovery management tools for individuals with SUD. WEConnect Health and DynamiCare Health are both offering free daily online recovery support groups.
Focus Area 3: Leveraging New Opportunities to Close the Treatment Gap
As has been widely documented, the pandemic has spurred unprecedented adoption of telehealth services, aided by new funding opportunities (offered through the CARES Act and similar channels) and the widespread easing of telehealth requirements, including the allowance of reimbursement for audio-only services and temporarily eased provider licensure requirements.
Tele-behavioral health services are no exception; the aforesaid trends ensure that what was one of the few high-growth areas in digital behavioral health before the pandemic will remain so for the foreseeable future. This is unquestionably a positive development, but there is still much work to be done to close the treatment gap. Critically, a meaningful portion of this work is beyond the reach of the virtual infrastructure that has been established to date. For example, there remains a dearth of solutions that have successfully scaled treatment models for individuals with acute illnesses, like SMI or dual BH-SUD diagnoses.
Health system leaders should continue to keep their ears to the ground for new opportunities to expand their virtual treatment infrastructure, paying particular attention to synergistic opportunities to build on investments in newly-developed assets (like workforce-focused solutions) to round out the continuum of behavioral health services.
COVID-19 has all but guaranteed that behavioral health will remain a major focus of efforts to improve healthcare delivery. Therefore, health systems that approach today’s necessary investments in behavioral health with a long-term focus will emerge from the pandemic response well ahead of their peers, having built healthier communities along the way.
About Victor Siclovan
Victor Siclovan is a Director on the Medicaid Transformation Project at AVIA where he leads work in behavioral health, chronic care, substance use disorder, and Medicaid population health strategy. Prior to AVIA, Victor spent nearly 10 years at Oliver Wyman helping large healthcare organizations navigate the transition to value-based care. He holds a BA in Economics from Northwestern.
DENVER — D.j. Mattern had her Type 1 diabetes under control until COVID’s economic upheaval cost her husband his hotel maintenance job and their health coverage. The 42-year-old Denver woman suddenly faced insulin’s exorbitant list price — anywhere from $125 to $450 per vial — just as their household income shrank.
She scrounged extra insulin from friends, and her doctor gave her a couple of samples. But as she rationed her supplies, her blood sugar rose so high her glucose monitor couldn’t even register a number. In June, she was hospitalized.
“My blood was too acidic. My system was shutting down. My digestive tract was paralyzed,” Mattern said, after three weeks in the hospital. “I was almost near death.”
So she turned to a growing underground network of people with diabetes who share extra insulin when they have it, free of charge. It wasn’t supposed to be this way, many thought, after Colorado last year was the first of 12 states to implement a cap on the copayments that some insurers can charge consumers for insulin. But as the COVID pandemic has caused people to lose jobs and health insurance, demand for insulin sharing has skyrocketed. Many patients who once had good insurance are now realizing the $100 cap is only a partial solution, applying just to state-regulated health plans.
Colorado’s cap does nothing for the majority of people with employer-sponsored plans or those without insurance coverage. According to the state chapter of Type 1 International, an insulin access advocacy group, only 3% of patients with Type 1 diabetes under 65 could benefit from the cap.
Such laws, often backed by pharmaceutical companies, give the impression that things are improving, said Colorado chapter leader Martha Bierut. “But the reality is, we have a much longer road ahead of us.”
The struggle to afford insulin has forced many people into that underground network. Through social media and word-of-mouth, those in need of insulin connect with counterparts who have a supply to spare. Insurers typically allow patients a set amount of insulin per month, but patients use varying amounts to control their blood sugar levels depending on factors such as their diet and activity that day.
Though it’s illegal to share a prescription medication, those involved say they simply don’t care: They’re out to save lives. They bristle at the suggestion that the exchanges resemble back-alley drug deals. The supplies are given freely, and no money changes hands.
For those who can’t afford their insulin, they have little choice. It’s a your-money-or-your-life scenario for which the American free-market health care system seems to have no answer.
“I can choose not to buy the iPhone or a new car or to have avocado toast for breakfast,” said Jill Weinstein, who lives in Denver and has Type 1 diabetes. “I can’t choose not to buy the insulin, because I will die.”
Exacerbated by the Pandemic
Surveys conducted before the pandemic showed that 1 in 4 people with either Type 1 or Type 2 diabetes had rationed insulin because of the cost. For many Blacks, Hispanics and Native Americans, the pinch was especially bad. These populations are more likely to have diabetes and also more likely to face economic disparities that make insulin unaffordable.
Then COVID-19 arrived, with economic stress and the virus itself hitting people in those groups the hardest.
This year, the American Diabetes Association reported a surge in calls to its crisis hotline regarding insulin access problems. In June, the group found, 18% of people with diabetes were unemployed, compared with 12% of the general public. Many are wrestling with the tough choices of whether to pay for food, rent, utilities or insulin.
Rep. Dylan Roberts, a Democrat who sponsored Colorado’s copay cap bill, said legislators knew the measure was only the first step in addressing high insulin costs. The law also tasked the state’s attorney general to produce a report, due Nov. 1, on insulin affordability and solutions.
“We went as far as we could,” Roberts said. “While I feel Colorado has been a leader on this, we need to do a whole lot more both at the state and national level.”
According to the American Diabetes Association, 36 other states have introduced insulin copay cap legislation, but the pandemic stalled progress on most of those bills.
Insulin prices are high in the U.S. because few limits exist for what pharmaceutical manufacturers can charge. Three large drugmakers dominate the insulin market and have raised prices in near lockstep. A vial that 20 years ago cost $25 to $30 now can run 10 to 15 times that much. And people with diabetes can need as many as four or five vials per month.
“It all boils down to cost,” said Gail deVore, who lives in Denver and has Type 1 diabetes. “We’re the only developed nation that charges what we charge.”
Before the COVID crisis triggered border closures, patients often crossed into Mexico or Canada to buy insulin at a fraction of the U.S. price. President Donald Trump has taken steps to lower drug prices, including allowing for the importation of insulin in some cases from Canada, but that plan will take months to implement.
The Kindness of Strangers
DeVore posts on social media three or four times a year asking if anybody needs supplies. While she’s always encountered demand, her last tweet in August garnered 12 responses within 24 hours.
“I can feel the anxiety,” deVore said. “It’s unbelievable.”
She recalled helping one young man who had moved to Colorado for a new job but whose health insurance didn’t kick in for 90 days. She used a map to choose a random intersection halfway between them. When deVore arrived on the dusty rural road after dark, his car was already there. She handed him a vial of insulin and testing supplies. He thanked her profusely, almost in tears, she said, and they parted ways.
“The desperation was obvious on his face,” she said.
It’s unclear just how widespread such sharing of insulin has become. In 2019, Michelle Litchman, a researcher at the University of Utah’s College of Nursing, surveyed 159 patients with diabetes, finding that 56% had donated insulin.
“People with diabetes are sometimes labeled as noncompliant, but many people don’t have access to what they need,” she said. “Here are people who are genuinely trying to find a way to take care of themselves.”
If insulin affordability doesn’t improve, Litchman suggested in a journal article, health care providers may have to train patients on how to safely engage in underground exchanges.
The hashtag #Insulin4all has become a common way of amplifying calls for help. People sometimes post pictures of the supplies they have to share, while others insert numbers or asterisks within words to avoid social media companies removing their posts.
Although drug manufacturers offer limited assistance programs, they often have lengthy application processes. So they typically don’t help the person who accidentally drops her last glass vial on a tile floor and finds herself out of insulin for the rest of the month. Emergency rooms will treat patients in crisis and have been known to give them an extra vial or two to take home. But each crisis takes a toll on their long-term health.
That’s why members of the diabetes community continue to look out for one another. Laura Marston, a lawyer with Type 1 diabetes who helped to expose insulin pricing practices by Big Pharma, said two of the people she first helped secure insulin, both women in their 40s, are in failing health, the result of a lifetime of challenges controlling their disease.
“The last I heard, one is in end-stage renal failure and the other has already had a partial limb amputation,” Marston said. “The effects of this, what we see, you can’t turn your back on it.”
The underground sharing is how Mattern secured her insulin before recently qualifying for Medicaid. When someone on a neighborhood Facebook group asked if anybody needed anything in the midst of the pandemic, she replied with one word: insulin. Soon, an Uber driver arrived with a couple of insulin pens and replacement sensors for her glucose monitor.
“I knew it wasn’t altogether legal,” Mattern said. “But I knew that if I didn’t get it, I wouldn’t be alive.”
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What You Should Know:
– Molina Healthcare acquires New York-based Medicaid managed care organization Affinity Health Plan for $330M in cash serving members in New York City, Westchester, Orange, Nassau, Suffolk, and Rockland counties.
– As of August 31, 2020, Affinity served approximately 284,000 Medicaid members. Affinity’s premium revenue for the trailing twelve months ended July 31, 2020, was approximately $1.3 billion.
– The net purchase price of approximately $380 million represents less than 30% of premium revenues for the twelve months ended July 31, 2020
– Through its locally operated health plans, Molina Healthcare served approximately 3.6 million members.
What You Should Know:
– NovuHealth and Revel merge to bring together NovuHealth’s
personalized healthcare loyalty programs with Revel’s applied behavioral
research and health action technologies.
– Together, Revel and NovuHealth work with more than 50
healthcare organizations, including seven of the top 10 largest health insurers
in the United States representing more than 65 percent of all members in
government programs such as Medicare and Medicaid.
Revel and NovuHealth, two of the nation’s leading
healthcare consumer engagement, communications and technology companies, today
announced a merger
of the companies effective immediately. The merger establishes Revel and
NovuHealth as the largest technology company focused on member engagement for
healthcare’s most trusted organizations.
Merger Establishes Largest Healthcare Member Engagement Platform
The merger establishes Revel and NovuHealth as the largest
technology company focused on member engagement for healthcare’s most trusted
organizations and delivers a next-generation SaaS platform that creates
omnichannel personalization at scale for healthcare. Together, Revel and
NovuHealth work with more than 50 healthcare organizations, including seven of
the top 10 largest health insurers in the United States representing more than
65 percent of all members in government programs such as Medicare and Medicaid.
Over the course of the next few months, the Revel and
NovuHealth teams will be working to merge their sales and marketing operations,
customer experience, operations and product teams. The new company will
continue to operate in growth mode and expects to add professional talent
through the balance of the year. The company will reveal a new brand for the
combined enterprise in the new year.
As part of the merger, NovuHealth CEO Steve Wigginton will
serve as CEO, while Revel CEO Jeff Fritz will transition to an advisor to the
CEO and the board of directors of the merged company.
“This merger creates a dream team of experts in consumer marketing, behavioral science, healthcare regulatory expertise, data science and technology,” said Jeff Fritz, CEO of Revel. “This is a rare opportunity to connect the complementary nature of the Revel and NovuHealth platforms to create personalization at scale for the most trusted healthcare organizations. The result is a platform designed to reach the full spectrum of members including the hardest to reach, noncompliant consumers who are the toughest to motivate to take healthy actions,” Fritz said.
The COVID-19 pandemic is not just a medical crisis. Since the highly contagious disease hit American shores in early 2020, the virus has dramatically changed all sectors of society, negatively impacting everything from food supply chains and sporting events to the nation’s mental and behavioral health.
For some people, work-from-home plans and limited access to entertainment are manageable obstacles. For others, the shuttered schools, lost wages, and social isolation spell disaster – especially for individuals already living with socioeconomic challenges.
The social determinants of health have always been important for understanding why some populations are more susceptible to increased rates of chronic conditions, reduced healthcare access, and shorter lifespans. COVID-19 is throwing the issue into high relief.
Now more than ever, healthcare providers need to gain full visibility into their populations and the non-clinical challenges they face in order to help individuals maintain their health and keep their communities as safe as possible during the ongoing pandemic.
Exploring correlations between socioeconomic circumstances and COVID-19 vulnerability
Clinicians and researchers have worked quickly to identify patterns in the spread of COVID-19. Early results have emphasized the danger posed by advanced age and preexisting chronic conditions such as obesity, diabetes, and heart disease.
Further, data from the Johns Hopkins University and American Community Survey indicates that the infection rate in predominantly black counties is three times higher than in mostly white counties. The death rate is six-fold higher.
Data from the Centers for Medicare and Medicaid Services (CMS) confirms the trend: black Medicare beneficiaries are hospitalized at a rate of 465 per 100,000 compared to just 123 per 100,000 white beneficiaries. Hispanic Medicare beneficiaries had 258 hospitalizations per 100,000, more than double the white population’s hospitalization rate.
Researchers suggest that the social determinants of health may be largely responsible for these disconnects in infection and mortality rates. Racial, ethnic, and economic factors are strongly correlated with increased health concerns, including longstanding disparities in access to care, higher rates of underlying chronic conditions, and differences in health literacy and patient education.
Leveraging data-driven tools to identify vulnerable patients
Healthcare providers will need to take a proactive role in identifying which of their patients may be at enhanced risk of contracting the virus and experiencing worse outcomes from the disease.
They will also need to ensure that person gets adequate treatment and participate in contact tracing efforts after a positive test. Lastly, providers will have to ensure their public health reporting data is accurate to inform local and regional efforts to contain the disease.
The process begins by developing confidence in the identity of each individual under the provider’s care. Healthcare organizations often struggle with unifying multiple electronic health record (EHR) systems and other health IT infrastructure, resulting in medical records that are incomplete, inaccurately duplicated, or incorrectly merged.
Access to current and complete medical histories is key for highlighting at-risk patients. An enterprise master patient index (EMPI) can provide the underlying technical foundation for initiating this type of population health management.
EMPIs help organizations create and manage reliable unique patient identifiers to ensure that records are always associated with the correct individual as they move throughout the healthcare system.
When paired with claims data feeds, health information exchange (HIE) results, and interoperability connections with other healthcare partners, EMPIs can bring a patient’s complete healthcare status into focus.
This approach ensures that providers stay informed about past and present clinical issues and service utilization rates. It can also support a deeper dive into the social determinants of health.
Combining EHR data with standardized data about socioeconomic needs can help providers develop more comprehensive and detailed portraits about their patients’ holistic health status.
By including this information in EHRs and population health management tools, providers can develop condition-specific registries to guide outreach activities. Providers can deploy improved care management strategies, close gaps in care, and connect individuals with the resources they need to stay healthy.
Healthcare organizations can acquire socio-economic data about their communities in a variety of ways, including integrating public data sources into their population health management tools and collecting individualized data using standardized questionnaires.
Once providers start to understand their patients’ non-clinical challenges, including the ability to avoid situations that may expose them to COVID-19, they can begin to prioritize patients for outreach and develop personalized care plans.
Conducting effective outreach and interventions for high-needs patients
COVID-19 has taken a staggering economic toll on many families, including those who may have been financially secure before the pandemic. Routine healthcare, prescription medications, and even some urgent healthcare needs are often the first to fall by the wayside when finances get tight.
Healthcare providers have gotten creative about staying connected to patients through telehealth, drive-in consults, and other contactless strategies. But they must also ensure that their vulnerable patients are aware of these options – and that they are taking advantage of them.
Contacting a large number of patients can be challenging since phone numbers, emails, and home addresses change frequently and are prone to data entry errors during intake. Organizations with EMPIs can leverage their tools to ensure contact information is up to date, accurate, and associated with the correct individual.
Care managers should prioritize outreach to patients with complex medical histories and known clinical risks for vulnerability to COVID-19. These conversations are a prime opportunity to collect social determinants of health information or refresh existing data profiles.
Looking to the future of healthcare in a COVID-19 world
Combining technology-driven strategies with targeted outreach will be essential for healthcare organizations aiming to provide holistic support for their populations during – and after – the COVID-19 pandemic.
By developing certainty about patient identities and synthesizing that information with data about the social determinants of health, providers can efficiently and effectively connect with their patients to offer much-needed resources.
Taking a proactive approach to addressing the social determinants of health during the outbreak will help providers maintain relationships with high-needs patients while building new connections with those facing unanticipated challenges.
With a combination of population health management strategies and innovative technology tools, healthcare providers and public health officials can begin to view the social determinants of health as a fundamental component of the fight against COVID-19.
Andy Aroditis, is CEO of NextGate, the global leader in healthcare enterprise identification.
Finding previously unidentified insurance coverage can feel a little like a game of hide and seek. Patients may not always be aware of their insurance or eligibility for Medicare and Medicaid, and, in an effort to both improve the patient financial experience and simultaneously improve collections, providers are often tasked with finding this information on the spot. Historically, providers have used demographic information like Social Security Numbers (SSN) as a means to verify patient identities and locate this information, but that tactic is increasingly unreliable as it is possible for more than one person to use the same SSN and SSNs are a lucrative route to stealing someone’s identity.
With this in mind, many health plans are no longer using SSNs as an identifying number for insurance coverage. In fact, the Centers for Medicare & Medicaid Services recently removed SSN-based Health Insurance Claim Numbers (HICNs) from Medicare cards and are now using Medicare Beneficiary Identifiers (MBIs) for Medicare transactions like billing, eligibility status, and claim status.
The latest health plans to remove this piece of demographic information is Health Net Medi-Cal and Health Net National. Effective September 25, 2020, the search options for eligibility for this plan have changed. Providers will ONLY be able to find and verify coverage with a subscriber ID.
“Providers are often tasked with finding this information on the spot.”
While Health Net Medi-Cal and Health Net National are the latest health plans to do away with demographic searches, it’s certainly not a surprising trend and more will likely follow suit.
Bridging the gap with historical data
Uncovering previously unidentified coverage is critical for providers as it helps to eliminate costly self-pay situations, bad debt write-offs and unwarranted charity designations. And, without the proper insurance information, patients also risk delayed access to care and other financial hardships.
With demographic searches on the decline, providers will need a more efficient and reliable way to search for coverage. As a data-driven company with a historical repository of claims data, Experian Health is uniquely positioned to help providers search for coverage.
Combining search best practices, multiple proprietary databases and historical information, Experian Health’s Coverage Discovery locates patients’ billable commercial insurances that were unknown or forgotten, and combs through Medicare and Medicaid coverage. This flags accounts that may have been destined as a write-off or charity and maximizes reimbursement revenue by identifying primary, secondary and tertiary coverage. Not only do fewer accounts go to bad-debt collections, but providers can automate the self-pay scrubbing process.
A tool like Coverage Discovery is even more beneficial for providers during COVID-19, where limitations of face-to-face contact make it more difficult to complete the usual coverage checks. Coverage Discovery empowers providers to facilitate coverage checks remotely, avoiding delayed reimbursements during a time when revenue streams are already feeling pressure.
“As a data-driven company with a historical repository of claims data, Experian Health is uniquely positioned to help providers search for coverage.”
Want to learn more? Contact us to see how Coverage Discovery can help find previously unidentified coverage and reduce bad debt.
The post Finding unidentified coverage without a Social Security Number (SSN) appeared first on Healthcare Blog.
Earlier this month, the Congressional Budget Office (CBO) gave an update to its federal budget projections between 2020 and 2030. As expected, things look grim for 2020.
CBO projects a federal budget deficit of $3.3 trillion in 2020, more than triple the shortfall recorded in 2019. That increase is mostly the result of the economic disruption caused by the 2020 coronavirus pandemic and the enactment of legislation in response. At 16.0 percent of gross domestic product (GDP), the deficit in 2020 would be the largest since 1945.
The deficit in 2021 is projected to be 8.6 percent of GDP. Between 1946 and 2019, the deficit as a share of GDP has been larger than that only twice
As we know, the federal government spent a lot of emergency funds to help stabilize the health care system in the wake of the COVID-19 pandemic. Where did the $225 billion lawmakers appropriated for the HHS Pulic Health and Soical Services Emergency Fund go?
CBO projects that the funding will result in $135 billion in outlays in 2020 and $89 billion in outlays over the 2021–2025 period. Most of the funding, $175 billion, was dedicated to reimbursing health care providers (such as hospitals) for expenses related to health care or lost revenues as a result of the coronavirus pandemic. The remaining amount, including $16 billion for the Strategic National Stockpile, can be used to support the development and purchase of vaccines, therapeutic treatments and drugs, and medical supplies.
As the economy declined, a larger share of individuals switched to government-funded health insurance. See how CBO projects federal health insurance spending to be impacted by the pandemic.
Medicare. Outlays for Medicare (net of offsetting receipts) will rise by 12 percent in 2020, from $644 billion in 2019 to $721 billion, CBO projects. That increase results in part from payments made to providers in 2020 in advance of expected health care claims. CBO expects that those payments will be recouped from providers in 2020 and 2021…
Medicaid: Outlays for the program will total $466 billion this year …an increase of $57 billion (or 14 percent) relative to spending in 2019. The deterioration in the economy has
caused enrollment in the program to rise. In addition, legislation has raised the portion of costs the federal government must cover and required that states maintain coverage for all Medicaid enrollees during the public health emergency regardless of any changes in their
income or circumstances that would otherwise have caused them to become ineligible for the program.
Over the next decade, expect Medicare finding to rise dramatically as the baby boomers retire whereas Medicaid spending–assuming know change in legislation–will be fairly stable as a share of the economy.
Outlays for Medicare, which equal 3.2 percent of GDP in 2021, rise to 4.3 percent of GDP in 2030.
Federal outlays for Medicaid remain relatively stable as a percentage of GDP over the coming decade, averaging about 2 percent each year.
Outlays for subsidies for health insurance purchased through the [ACA] marketplaces and related spending are projected to average 0.2 percent of GDP per year through 2030.
- Congressional Budget Office. An Update to the Budget Outlook: 2020 to 2030. September 2020.
While all eyes and ears are focused on COVID-19 and beating this pandemic, the administration has pursued harmful policy changes that we can’t let slip under the radar. In two back-to-back regulatory actions in recent months, the administration has taken steps to make it harder for biopharmaceutical manufacturers to offer assistance to commercially insured patients. Why do these changes matter? Both could lead to patients being forced to pay more out of pocket for their medicines in the middle of a public health and economic crisis, when we should be doing the exact opposite – finding ways to lower costs for patients.
The Trump administration’s latest effort to use COVID-19 rapid tests — touted by one senior official as a “turning point” in arresting the coronavirus’s spread within nursing homes — is running into roadblocks likely to limit how widely they’ll be used.
Federal officials are distributing point-of-care antigen tests — which are cheaper and faster than tests that must be run by a lab — to 14,000 nursing homes to increase routine screening of residents and staff. The initial distribution targets nursing homes in hot spots and those with at least three COVID-19 cases, senior Trump administration officials said in July, hailing it as a tool that could root out asymptomatic carriers who might still infect others.
But there’s a hitch: Two manufacturers that have received Food and Drug Administration authorization and whose instruments are being delivered — Becton, Dickinson and Co., known as BD, and Quidel — say their antigen tests are intended for patients with symptoms, calling into question how valuable the tests would be for broad screening purposes. The Centers for Disease Control and Prevention estimates 40% of infected people may be asymptomatic.
“It’s important always to use a diagnostic in the way that it has been designed to be used,” said Elizabeth Talbot, New Hampshire’s deputy state epidemiologist. “We simply don’t know how [the tests] will perform in persons who are asymptomatic.”
Perhaps the highest-profile example of the problem occurred in Ohio this month, when Gov. Mike DeWine had no symptoms and tested positive for COVID-19 with Quidel’s antigen test. Within hours, the Republican governor’s diagnosis was reversed after he got a PCR test.
“People should not take away from my experience that testing is not reliable or doesn’t work,” DeWine said on CNN after his false-positive diagnosis. “The antigen tests are fairly new,” he said. “We’re going to be very careful in how we use it.”
The bigger problem is false-negative results, which show someone isn’t infected when they actually are. BD’s false-negative rate — how often a test incorrectly says someone isn’t infected — is about 15%; Quidel’s is 3%.
Quidel and BD say their tests are intended to be used for people within the first five days of showing symptoms. A spokesperson for BD said its test should not be used on asymptomatic individuals. Quidel through a spokesperson deferred to FDA guidelines, which allow asymptomatic testing in certain scenarios.
“For routine surveillance, this is a great tool and these are our best tools that we have available,” said Adm. Brett Giroir, assistant secretary for health at the Department of Health and Human Services, on a July call with nursing home officials, according to a recording obtained by KHN. Seema Verma, the administrator of the federal Centers for Medicare & Medicaid Services, on the call referred to the effort as a “turning point” in the fight against the virus.
A month after the initial announcement, the Trump administration invoked the Defense Production Act to bump its contracts with the two companies to the front of the line and expedite shipments. BD will send roughly 11,000 devices and 3.75 million tests to nursing homes; Quidel and HHS declined to answer questions about its volume.
As states and the federal government move to mandate COVID testing inside nursing homes, whose patients are deemed highly vulnerable to infection and severe complications, several industry officials have said they hoped to use the tests on asymptomatic people. But many states restrict the use of antigen tests or still require lab-based testing because of accuracy concerns.
If a person with a negative test result has to default to getting a more accurate PCR test, “then we simply have just added time and cost,” Talbot said. “That’s a problem.”
Officials said the antigen test announcement caught them by surprise, underscoring the administration’s chaotic testing strategy. Separate from the federal effort, 10 states have banded together through the Rockefeller Foundation to secure 5 million tests from the two companies in hopes of curbing the virus’s spread this fall.
After nursing homes receive an initial batch of tests — each facility gets between 150 and 900 — they would have to buy future supplies. Medicare will cover the costs of diagnostic tests but not expenses for routine surveillance.
“I just have a lot of skepticism,” said Brendan Williams, president of the New Hampshire Health Care Association, which represents nursing homes and assisted living facilities in the state. “Basically you’re giving some lousy tests for nursing homes and you’re making them pay for them. I don’t see that as a win; I see that as a risk.”
Public health experts have become increasingly vocal that frequent rapid testing is the best tool for stopping the virus — which has killed more than 174,000 Americans including tens of thousands in nursing care — rather than relying on more accurate lab-based tests that have been plagued by delays and shortages. In a call this month with the industry, Verma estimated that half of the country’s nursing homes have experienced cases.
“I don’t see an avenue where these will not help to stop transmission chains, and I don’t see another option on the table for us,” said Dr. Michael Mina, an assistant professor of epidemiology at the Harvard T.H. Chan School of Public Health and a proponent of rapid tests. “It is what we need to be doing right now.”
“This is better for the folks in our buildings, without a doubt,” added Jason Belden, director of emergency preparedness and physical plant services for the California Association of Health Facilities.
In theory, antigen tests can serve dual purposes — diagnosing a person with a suspected infection or screening a group of people to more quickly identify sick individuals. The tests by Quidel and BD, under their FDA authorizations, can be used on certain asymptomatic individuals, including those suspected of having COVID-19 after exposure to an infected person. The companies would need additional FDA authorization to screen any asymptomatic person regardless of whether they’re suspected of being sick, according to agency guidelines.
The CDC has suggested antigen tests could be useful in high-risk settings if performed repeatedly. It said there was limited data to guide using them to screen asymptomatic people.
Nonetheless, HHS recommends universal screening of nursing home residents at least once and regular screening of staff regardless of symptoms, said agency spokesperson Mia Heck, citing the fact that COVID-19 viral loads are similar between patients with and without symptoms. “Only one test in the U.S. is authorized for asymptomatic individuals,” she said, referring to a PCR test from LabCorp, “yet the overwhelming majority of testing is being done on asymptomatic individuals.”
“If the world were ideal we’d say, ‘Oh, we want the more accurate test.’ But the more accurate test takes forever to get the results back,” said Peter Van Runkle, executive director of the Ohio Health Care Association, which represents the state’s nursing homes.
All targeted nursing homes will receive tests by the end of September, according to federal officials, who recently announced that facilities in states with a positivity rate of at least 5% must test staff each week.
“I don’t see this as a federal strategy so much as a stopgap method to bring a little relief to nursing homes,” said Katie Smith Sloan, president of LeadingAge, which represents nonprofit nursing homes. “It’s really tragic that we are where we are right now.”
Boosted by $71 million in federal funds for Quidel and $24.3 million for BD, Quidel plans to produce 1.8 million tests weekly by September; BD will produce similar volumes by October.
“The situation is much too urgent to wait a few months so we can put bows and lipstick on the program. So we’re going to build this plane a little bit while we’re flying it,” Giroir told nursing homes in July. “Just work with us. We want to get you what you need. And then in September, October you can get what you want.”
States take different approaches in deploying antigen tests in nursing homes; in at least seven — including California, Illinois and Maryland — officials say PCR tests should still be used to confirm results or to screen patients without symptoms. In Massachusetts, nursing homes must use PCR tests to meet surveillance requirements.
In Maryland, “our goal is to screen out staff who are positive as quickly as possible, particularly asymptomatic folks,” said Dennis Schrader, chief operating officer of the health department.
Maryland nursing homes can use antigen tests for weekly staff testing if there isn’t an outbreak. But if at least one person tests positive for the coronavirus, all staff and residents must be tested with PCR tests.
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In a near-empty arena on the river in his hometown of Wilmington, Delaware, former Vice President Joe Biden accepted the Democratic nomination for president, promising hope over fear, fairness over privilege, love over hate.
And, he said, “Facts over fiction.”
Let’s see about that.
Our partners at PolitiFact examined a range of claims made by Biden, fact-checking or putting them in context. Here are excerpts related to health policy and the COVID-19 pandemic:
“Five million Americans infected with COVID-19.”
It’s a little higher than that. According to data from Johns Hopkins University, the number of positive tests as of Aug. 20 was 5,573,517.
“More than 170,000 Americans have died.”
This is accurate. Johns Hopkins data counted 174,248 U.S. deaths through Aug. 20.
“More than 50 million people have filed for unemployment this year.”
This, too, is accurate. Since March 21, 57.4 million Americans have filed initial unemployment claims.
“By far the worst performance of any nation on Earth.”
The United States leads the world in the number of COVID-19 cases and deaths. Using other metrics that account for population, the U.S. isn’t the absolute worst, but it still lags behind many other countries. For instance, the United States has the fifth-highest death rate per 100,000 people.
The virus is known to have infected a higher percentage of the population in the U.S. than in many other places. The U.S. has one of the highest rates globally of people who have tested positive — 16,430 per million residents, which is lower than Chile’s, but higher than that of any other large country.
“More than 10 million people are going to lose their health insurance this year.”
This number may be an underestimate. In a July report, the Urban Institute estimated that from April through December 2020, 10.1 million people will lose health insurance tied to a job that they lost during the pandemic. This analysis was done by looking at employment loss projections data from U.S. Labor Department reports.
But that number is lower than another estimate. KFF estimates that nearly 27 million people could lose their employer-sponsored health insurance and become uninsured due to the COVID-19 pandemic. (KHN is an editorially independent program of KFF, the Kaiser Family Foundation). This 27 million figure includes both those who lost employer-sponsored insurance as well as dependents who may have been covered on the same plan. The estimate was based on assessing data from Labor Department unemployment claims and determining whether workers were eligible for ACA insurance.
“The assault on the Affordable Care Act will continue until it’s destroyed, taking insurance away from 20 million people, including more than 15 million people on Medicaid. And getting rid of the protections that President Obama worked so hard to get passed.”
Biden was referring to the coverage losses that would result if a Trump administration-backed lawsuit to overturn the Affordable Care Act is successful. And health policy experts and press reports cite numbers close to what Biden listed.
Close to 20 million people gained health insurance after the Affordable Care Act was enacted, either through the Medicaid expansion or as a result of its marketplace subsidies for individuals below 400% of poverty. So, it follows that if the ACA were overturned, their health coverage would be at risk.
Additionally, an Urban Institute estimate matches Biden’s 15 million figure regarding how many people would lose Medicaid coverage if the ACA were struck down. That would be a result of the federal government no longer helping states pay for Medicaid expansion.
There are other estimates that take into account the effects of the COVID-19 pandemic. The left-leaning Center for American Progress estimates that 3 million additional people (beyond the already estimated 20 million) could lose health insurance coverage because of COVID-19 and be eligible for other government programs, such as Medicaid.
And because the ACA ensures that those with preexisting conditions must be covered by health insurance, that “protection,” as Biden called it, would no longer be in place if the law were overturned, because President Donald Trump has not issued a health care plan that would offer a similar guarantee.
“And after all this time the president still does not have a plan” for the COVID-19 pandemic.
It’s unclear exactly what type of plan Biden is referring to in this general statement. It is true that, thus far, no national testing or contact tracing plan has been issued. Nor has the White House issued a national blueprint to address the COVID-19 pandemic, despite Trump saying he would do so in July.
“We are in the process of developing a strategy that’s going to be very, very powerful. We’ve developed as we go along,” Trump said July 21.
However, the White House has said that Trump does have a plan. Several plans, in fact, seem to have emerged.
Part of one Trump administration plan included restricting travel from areas that have been affected by the virus in March. This initially targeted only China, but then extended to Iran, Italy, South Korea and other European countries. The White House also said Trump worked to expand testing capacity by developing a public and private partnership that would bring more coronavirus testing to parking lots of big-name chain stores. (There were only a few in operation when we checked in April.)
Trump has also touted a plan to develop a COVID-19 vaccine as quickly as possible, called Operation Warp Speed. The goal of Operation Warp Speed is to deliver 300 million doses of a COVID-19 vaccine by January 2021. A federal plan for vaccine distribution is not yet ready.
Throughout the COVID-19 pandemic, Trump has emphasized he wanted state leaders to take control of virus response within their states. But critics say these efforts do not represent a coordinated strategy.
“We’ll have a national mandate to wear a mask, not as a burden, but to protect each other.”
A nationwide mask mandate is easier said than done, given current law.
The Congressional Research Service found that the Centers for Disease Control and Prevention could use the Public Health Service Act (Sec. 361) to issue regulations mandating the use of masks. But a mandate would likely run into legal problems with the Constitution and other laws, including the Religious Freedom Restoration Act of 1993, which requires courts to grant certain religious exemptions.
Meanwhile, the Supreme Court’s interpretation of the 10th Amendment prevents the federal government from controlling or requiring states to carry out federal directives. Congress could incentivize states to enact mask mandates, as long as the incentives aren’t considered significant enough to coerce or force states into enacting the mandate, the CRS report said.
A number of courts have affirmed state and local authority to impose social distancing measures and temporary business closures. Opponents of masks say that the requirement violates their First Amendment rights. At least one federal court has already rejected this claim and said the requirement regulates conduct, not speech.
Daniel Funke, Louis Jacobson, Victoria Knight, Bill McCarthy, Samantha Putterman, Amy Sherman and Miriam Valverde contributed to this report.
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A recent analysis by IQVIA shows that chronically ill patients who used manufacturer cost-sharing assistance in 2019 saved hundreds to thousands of dollars on their out-of-pocket costs. IQVIA found that nearly one-third of commercially insured patients taking brand anticoagulants, diabetes or oncology medicines used manufacturer assistance to help pay their cost sharing for one or more prescriptions, along with more than half of patients taking brand HIV medicines and 70% of patients taking brand multiple sclerosis medicines. For many patients facing high out-of-pocket cost burdens, manufacturer cost-sharing assistance programs are an important source of financial support which can help to improve patient adherence and lead to improved patient outcomes.
Addus HomeCare Corporation (Nasdaq: ADUS) is rebounding from coronavirus-related disruption in its personal care and home health segments, company leadership noted Tuesday during a second-quarter earnings call.
But the Frisco, Texas-based company also acknowledged there are still significant challenges on the horizon.
“Addus had a very solid financial performance for the second quarter of 2020, with volume levels not as heavily impacted by the ongoing COVID-19 environment as we originally thought,” Addus CFO Brian Poff said on the call.
As an in-home care provider, Addus provides a mix of personal care, hospice and home health care services. It currently provides those services to about 42,000 individuals across 25 states and 185 locations.
Addus recently expanded that footprint. Last month, it announced it had closed on a deal to acquire A Plus Health Care Inc., a Kalispell, Montana-based home care provider.
Personal care services accounted for nearly 85% or Addus’s overall Q2 revenue, a total of about $156.3 million. Hospice accounted for about 13% of Q2 revenue, with home health accounting for the remainder.
Overall, net service revenues for Addus were up nearly 24% year-over-year in Q2, jumping to $184.6 million from $148.9 million in 2019.
The road to recovery
Patients shied away from care at the beginning of the public health emergency, Addus leadership noted.
That caused Addus to hit a low point in visit volume for all three of its segments in April, with personal care services contracting from about an average billable total of 39,000 in Q2 2019 to a little over 36,000 in Q2 2020.
But the damage was somewhat contained and volume is trending upward, Addus CEO Dirk Allison said on the call.
“As we see the return of these patients, when they become more comfortable with services provided in their homes, our personal care census should continue to recover,” Allison said.
Home health was actually the hardest hit, but also the quickest to rebound, according to the company. Since then, it has seen Medicare referrals for home health increase to the point of pre-COVID-19 levels.
Addus received $6.9 million related to its Medicare business from the Provider Relief Fund, but decided to return it.
For one, both Addus management and the board felt that the company had a strong capital structure — with little debt — that could sustain itself without the money provided. It also felt like it was the right thing to do.
“[We want to] let others who need these funds have access to the money,” Allison said.
Additionally, it felt uncomfortable not knowing what future federal reporting and audit requirements could come about after accepting money from the fund.
While it hasn’t impacted revenue, Addus is also actively taking COVID-19 patients in each of its segments.
“While the past five months have been challenging, I remain optimistic about the future of the home care industry and Addus, in particular,” Allison said. “We have a dedicated team of leaders and team members that have demonstrated their ability to continue to meet our mission — even if this virus has disrupted the way we have historically operated.”
Despite a strong quarter, the Addus leadership team was frank about the challenges that the company is currently facing and the ones it will continue to face.
It’s going to have to deal with a slew of state-by-state specific problems, such as minimum wage hikes in Chicago to $14 — and eventually $15. It will also have to consider and adjust to fluctuating state budgets after COVID-19, particularly as it pertains to its Medicaid side of the business.
“[Still], I think one thing to remember is our services are keeping folks in their home and isolated and are one of the best ways to try to protect them from this virus,” Allison said. “It also is an alternative to those folks potentially being in a nursing home setting, which we all know has been a problem during this particular virus. … So we feel that we have a great story to tell.”
Allison added that he believes that the states understand the severity of the situation and the benefits of the home-based care setting versus facility-based care.
Addus is also expecting its personal protective equipment (PPE) expenses, which have been a significant add-on, to be a part of the company’s budget for the foreseeable future.
“We believe this additional expense will be necessary for the next several quarters or until an effective vaccine or treatment is developed and widely available,” Allison said.
The company is also dealing with recruiting issues for the time being, but is hoping that lower unemployment benefits from the federal government and workers transferring to home-based care from other fields will help solve the problem.
“Recruiting has been a little bit of a struggle, I think, primarily due to the additional unemployment benefits that [have been out] there,” Addus COO Brad Bickham said on the call. “We’re getting a lot of inbounds, but frankly we’re also seeing a lot of folks that won’t show up for training or for interviews. So recruiting is honestly a little down, [but] I expect it to improve with the reduction of the $600 [per week in unemployment benefits].”
The company also plans to lure some unemployed workers back to work with some incentives in a few markets, but didn’t specify what those would be.
Historically, hiring has been better for Addus during economic downturns.
“That’s been a better time for us to be able to hire and bring folks on, and we believe that will occur over the next year or two as the unemployment benefits … come to an end,” Bickham said. “We do believe that the recruitment efforts will return to a more historical level and hopefully [get] somewhat better.”
The post Addus COO: Recruiting Has Been ‘a Little Bit of a Struggle’ During COVID-19 appeared first on Home Health Care News.
In the late 1940s, the United Kingdom was busily reassembling country and what remained of the empire in the aftermath of World War II. Among many revelations, the war had convinced Britain’s leaders of the need to provide healthcare for all in the event of calamity upending the basic functions of a civilized society. With that, the UK’s National Health Service (NHS) was born.
In 2020, all perspectives about quality and the time it takes to see a provider aside, the NHS remains quite popular among UK citizens and is an enduring source of national pride.
With the United States in the midst of its own upheaval, it’s for a related question: Might the current COVID-19 situation give rise to significant changes to the American healthcare system?
Virtually no one thinks the correct answer is ‘No.’ Things will change. The question is how and to what extent. The healthcare system in place in the United States now is dramatically more complex than that in use by Britons after WW II. There are so many moving parts, so many things that can break.
So, in which aspects of the current American healthcare system are we likely to see changes after COVID-19 is dealt with?
Telehealth: Someone always benefits in a catastrophe. In this case, that someone may be Zoom shareholders.
From 10 million daily users in December, Zoom rocketed to 200 million in March and nearly 300 million a month later. Much of that was healthcare related.
Of course, Zoom is not the only direct beneficiary of coronavirus as venerable meeting platforms like WebEx and Skype, among others, have also experienced dramatic growth.
Hospitals and health systems were incrementally implementing telehealth services prior to the coronavirus outbreak, but there was no sense of urgency that accompanies a rapidly spreading virus. Since then, the federal government, states and insurance companies have allocated funds and rewritten regulation to expand the use of telehealth.
But there are more telehealth related-issues to address, some of which have thorns. Service and payment parity across insurance companies is an issue. If telehealth is going to be a regular component of healthcare, technology gaps will have to be addressed, especially in rural areas.
This is something the federal government recognizes. The White House recently drafted an executive order oriented around improving rural health by expanding technology access, developing new payment models and reducing regulatory burdens. The EO tasks the secretaries of health and human services and agriculture to work with the Federal Communications Commission to “develop and implement a strategy to improve rural health by improving the physical and communications healthcare infrastructure available to rural Americans.” But until Congress gets involved and provides funding for something like this, it will probably never get out of the proposal phase.
In fact, there are enough concerns—parity, technology gaps, added costs—associated with telehealth to wonder if it will endure after coronavirus is in the rear view. Enough about telehealth benefits both providers and patients for it to stick and proliferate, but that could also be said about any number of healthcare initiatives that seem to languish for lack of coordination and political will.
Health Insurance: This is where the NHS analogy is the most relevant. Many millions of workers are furloughed or simply laid off with the impact of COVID-19 on frontline jobs like restaurant worker, massage therapist and barista. Those who had insurance through work may not have it anymore, leaving them doubly vulnerable—no coverage, no income—to illness or accident.
Mass unemployment episodes reveal, each time, the weakness in the patchwork employment-based healthcare insurance system we’ve sort of made peace with for decades. Sure, Medicaid exists to fill the gaps, but it may make sense to render Medicaid unnecessary, especially since its value is questionable in particular states.
“You notice the number of band-aids that Congress is having to apply to help people who have lost their jobs,” said former CMS Administrator Don Berwick, MD. “What we have now is a whole series of band-aids and special measures. What if instead, we just had universal health insurance?”
What if, indeed. Will COVID-19 be the straw that burns the bridge of employer-based health insurance, to mangle a metaphor? That may depend on how long the pandemic lasts, who is president sometime after November 3 and how much damage is done to the national fabric before economy and society start a process of repair.
Payment Models: For years now, hospitals have been in the middle of slow shift from fee-for-service care to value-based care and alternative payment models. That transition didn’t happen quickly enough to prevent most hospitals from falling into a financial chasm. If elective procedures are a big part of revenue, it follows that revenue will fall if those procedures disappear.
To be fair, the hit to hospital finances has been catastrophic enough—more than $200 billion in losses over four months, according to the American Hospital Association—that federal government support would have been necessary even if a full pay-for-quality model had been in place.
But the pandemic spotlights the downside of treating essential services like healthcare as though they are mere services one selects or rejects. And it exposes the folly of not making sure everyone has insurance coverage (a payer) when the individual costs for COVID-19-related hospital admission can range from $20,000 to $88,000.
End-of-Life Care: According to one analysis, 42 percent of COVID-19 deaths have occurred in nursing homes or assisted living facilities. The families of those unfortunate souls who’ve died while in a facility have generally endured the agony of saying goodbye outside a window or over a video link. It’s hard to believe, after COVID-19, that the assisted living industry will continue as before.
“The crisis surely will lead nursing home administrators to reconsider the way patients are cared for,” says Modern Healthcare. “Among the ideas Harvard’s [Professor David] Grabowski believes will get a longer look in the wake of the pandemic are using telemedicine services, creating specialized Medicare Advantage plans for the homes and pursuing smaller settings.”
Perhaps. And perhaps a son or daughter that remembers coronavirus will simply choose not to risk everything by putting their parent in a home. Could enough of them make such a decision that the industry contracts? Is forced to take quality care more seriously? Attracts more serious federal regulation?
As the deaths mount, it’s hard not to give every option serious consideration.
Supply Chain: These days we’re bickering in public and on social media (looking at you, maskless Karen throwing food in Trader Joes) about whether or not masks should be mandated. Look back with me to February, however, and you’ll fondly recall concerns about there being enough masks at all.
Back then we learned that the United States had exactly one mask manufacturer, and that all other masks are sourced from overseas. That it takes longer to get stuff from China than from Amarillo creates obvious potential problems when a crisis hits, but it also pits hospitals and government entities against one another and guarantees that the winner will pay more for supplies than they would in less-critical times.
It also creates weird, unnecessary scenarios that could be avoided using coordination and leadership. The governor of Maryland, for example, used his wife’s connections to South Korea (her country of birth) to secure 500,000 coronavirus tests, which he then put in an undisclosed location and protected using national guard troops.
What’s the remedy?
Modern Healthcare has called for a national supply chain czar, which in other times may have just been the head of FEMA. The suggestion, however, highlights the need for a coordinated central clearing house where supplies can be ordered, managed and dispersed based on need.
Individual hospitals, clinics and health systems can also help themselves by using a robust supply chain software system that keeps track in real time of available supplies, covers all ordering systems and methodologies, and reacts swiftly to certain thresholds.
The uniquely unfortunate aspect of the American political system among western democracies is that, for the most part, it responds to the demands of special interests. Think about your local representative. Chances are good the shouts of specific business interests are ringing in his or her hears so loudly that little else is audible.
As such, there is a significant danger that the American healthcare system will return, post-COVID-19, to the same dynamic it had when the virus arrived, which will be unfortunate. What we need post-pandemic is not necessarily specific changes to hospitals, clinics, insurance companies, etc., though they could be part of an overall solution. What will be necessary is an examination of where every aspect of the healthcare system overall, inasmuch as there is one, didn’t do its job.
Disasters are social sodium pentothal that, while active, force groups of people to take an honest look at their failures. Once the disaster is passed, however, there is a danger that Upton Sinclair’s maxim—“It is difficult to get a man to understand something when his salary depends upon his not understanding it”—will rule the day.
No one hopes for more dramatic damage to the American economy and social fabric, but the irony is that necessary change sometimes only comes when reality is undeniable, as in a shellshocked Britain instituting the NHS. If COVID-19 doesn’t shock us sufficiently into making substantial changes to the healthcare system, it’s a pretty safe bet the same disaster will occur again.
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President Donald Trump keeps promising to unveil a comprehensive plan to replace the Affordable Care Act, but it keeps not appearing. However, this week he did order an expansion of telehealth for Medicare beneficiaries and a program to help struggling rural hospitals.
Meanwhile, the administration still lacks a comprehensive plan to fight the COVID-19 pandemic in the U.S., and Congress remains unable to agree on another round of COVID relief funding, despite broad agreement on the need.
Outside Washington, Missouri this week became the sixth state where voters approved an expansion of Medicaid under the Affordable Care Act over the objections of Republican governors and/or Republican-controlled legislatures.
This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Tami Luhby of CNN and Kimberly Leonard of Business Insider.
Among the takeaways from this week’s podcast:
- If a compromise over a federal relief package is not reached, Trump said he will issue executive orders to provide enhanced unemployment benefits and protections for people facing eviction. Even if he can do that, other parts of the stimulus plan — including money for states and local governments facing major deficits, schools, and testing and tracing programs — will likely be out of luck.
- Six states announced this week they are banding together to purchase quick-turnaround coronavirus tests as they try to increase the number of tests they can offer.
- States that have been using National Guard troops during the coronavirus emergency to help provide services are facing the prospect of having to pick up part of the cost for those service members. The mobilization was set to expire soon, but this week the administration announced it would extend the use of the National Guard, if states helped pay for it.
- No new health plan was offered by Trump despite his comments in an interview with Fox News anchor Chris Wallace two weeks ago that a plan would be unveiled by Aug. 2. Instead, the administration has rolled out a number of smaller initiatives, including proposals to lower prescription drug prices and extending telemedicine.
- The loosening of Medicare’s rules for telehealth during the pandemic has proved popular and may be hard to roll back. It has helped overcome shortages of medical professionals in rural areas and in mental health services. Nonetheless, federal officials and some health policy analysts suggest that increased use of digital medical appointments could expand the nation’s overall health bill. For example, if a patient has a virtual visit with the doctor who then says the patient needs to be seen in person, the doctor can collect fees for two visits.
- Among the big supporters of the Missouri measure to expand Medicaid was the health care industry, which spent heavily on the campaign.
- It’s second-quarter earnings season, and most health care companies are reporting good profits, despite the upheaval caused by the coronavirus. Still, they warn that they could take a hit in the third quarter.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:
Julie Rovner: Vanity Fair’s “How Jared Kushner’s Secret Testing Plan ‘Went Poof Into Thin Air’,” by Katherine Eban
Alice Miranda Ollstein: The Atlantic’s “How the Pandemic Defeated America,” by Ed Yong
Kimberly Leonard: The New York Times’ “’The Biggest Monster’ Is Spreading. And It’s Not the Coronavirus,” by Apoorva Mandavilli
Tami Luhby: The Washington Post’s “Trump Keeps Promising an Overhaul of the Nation’s Health-Care System That Never Arrives,” by Anne Gearan, Amy Goldstein and Seung Min Kim
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Despite strong opposition from Republicans and rural voters, Missouri on Tuesday joined 37 states and the District of Columbia in expanding its Medicaid program. Voters in Missouri approved creating a state constitutional amendment that will open Medicaid eligibility to include healthy adults starting July 1, 2021.
Voters approved expansion by a margin of 6.5 percentage points.
Missouri joins five other mostly conservative states that have passed Medicaid expansion via ballot initiatives — most recently, Oklahoma, on June 30. Most of the remaining 12 states that have not expanded Medicaid are Republican-leaning states in the South.
Nika Cotton, owner of Soulcentricitea, a new tea shop in Kansas City, Missouri, woke to the news on Wednesday morning. Cotton, whose children are 8 and 10, said she will qualify for health care coverage under the expansion.
“It takes a lot of stress off of my shoulders with having to think about how I’m going to take care of myself, how I’m going to be able to go and see a doctor and get the health care I need while I’m starting my business,” Cotton said.
Medicaid expansion, which states have the option of adopting as part of the Affordable Care Act, extends eligibility in the program to individuals and families with incomes up to 138% of the federal poverty level. A family of three, like Cotton’s, could make up to $29,974 to qualify.
The federal government pays for 90% of expansion costs.
As of 2018, 9.3% of Missourians were uninsured. And in 2019, researchers from Washington University in St. Louis estimated that around 230,000 people in Missouri would enroll for Medicaid if it were expanded. The study also showed expansion would save the state an estimated $39 million a year, largely by eliminating the need for other state health spending.
Missouri’s adoption of expansion follows a trend of increasing support in largely Republican states, according to health policy expert Rachel Nuzum of the Commonwealth Fund.
“What we’ve seen in our surveys over the years is when you take the labels off of the policies, when you take the Affordable Care Act label off, when you take Medicaid expansion off, and just start asking people whether or not you think low-income families should have access to Medicaid coverage, the support is overwhelming,” Nuzum said.
Support for expansion came largely from voters in and around Missouri’s urban centers such as Kansas City, St. Louis, Springfield and Columbia. In Kansas City for example, 87.6% of voters backed the measure.
Amendment 2 was rejected overwhelmingly by conservative voters in the mostly rural parts of the state that have the highest uninsured and poverty rates. Voters in McDonald, Morgan and Scotland counties, which have the three highest uninsured rates in the state, rejected the measure by margins of nearly 2-to-1 or greater.
Expansion opponents warned that high enrollment in the program could lead to the state’s 10% share of the costs becoming a significant burden for Missouri, especially when state revenues are down.
“When state revenues fall, it begs the question, how are you going to pay for this?” said Ryan Johnson, in late July. He is a senior adviser for United for Missouri, a conservative policy advocacy organization.
“We’re concerned that they are going to have to raid public education,” he said, “and that’s a disservice to the kiddos who hope to go back to school this fall, the teachers, the administrators and everyone involved in the public education system.”
Responding to declining revenue related to the coronavirus, Missouri’s Republican governor, Mike Parson, recently reduced the 2021 budget by nearly $449 million, with education taking the hardest hit.
Health care experts have said that the economic effects of the pandemic, including high unemployment and lower state revenue, could strain the capacity of state Medicaid programs. However, health care advocates argue that expansion benefits individuals and families struggling as a result of the pandemic, and the influx of federal dollars and the jobs that result from expansion could help the economy.
“If we’re worried about the economy and we’re worried about people working, Medicaid expansion is actually a way to encourage people to work and not have that worry they’re going to lose health insurance for themselves or their families,” said Ryan Barker, vice president of strategic initiatives for Missouri Foundation for Health.
Republican state lawmakers have fiercely resisted Medicaid expansion. The expansion question was placed on the ballot after a petition.
Expansion advocates enlisted the Fairness Project, a Washington, D.C.-based campaigning organization, in developing and executing their campaign strategy. The Fairness Project has been involved in successful Medicaid expansion campaigns in other mostly conservative states, including Maine, Utah, Idaho, Nebraska and Oklahoma.
The “YES on 2” campaign was supported by a wide range of groups, including the Missouri Chamber of Commerce and Industry, the Missouri Hospital Association, the NAACP, the AFL-CIO and the AARP, among others. And, the coalition forged unlikely alliances, including Planned Parenthood supporters and Catholic Charities of St. Louis, which is operated by the Archdiocese of St. Louis.
YES on 2 campaign material made almost no mention of the Affordable Care Act, which has been unpopular in Missouri, and some of its flyers didn’t use the words “Medicaid expansion.”
Although support for the measure was much lower in conservative rural areas, Fairness Project executive director Jonathan Schleifer said Missouri’s expansion success relied on both activating progressive urban voters and engaging rural voters — though conservative resistance remained a significant obstacle to reforming health care policy.
“I think there’s still a lot of work to do to push back against the hundreds of millions of dollars, the public messages coming from as high as the White House, that there’s something wrong with the Affordable Care Act,” Schleifer said.
Opponents to expansion included Gov. Parson and other Republican lawmakers, Missouri Right to Life, Missouri Farm Bureau and Americans for Prosperity.
In the days leading up to the election, the “No on 2 in August” campaign sent a mailer suggesting that expansion would lead to an influx of undocumented immigrants seeking health care, but undocumented immigrants are not eligible for Medicaid and would not be under expansion, either.
The flyer, which featured a man in a medical mask emblazoned with the Mexican flag, read “Amendment 2 Means Illegal Immigrants Flooding Missouri Hospitals … While We Pay for It!”
The “No On 2 in August” campaign did not respond to requests for comment about the flyer.
Between serving customers on a busy morning on Wednesday, shop owner Cotton said her excitement about expansion was only slightly diminished by having to wait almost a year for it to take effect.
“It’s better late than never,” said Cotton. “The fact that it’s coming is better than nothing.”
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Telehealth has quickly transformed the healthcare industry. Rather than scheduling an appointment, waiting up to a few weeks, and going to a doctor’s office or another healthcare facility, we can now access many types of care from the convenience of our smartphones.
However, telehealth has also brought in its own set of new challenges that must be overcome for it to be successful in the long term. Below, we explore five of the biggest issues telemedicine faces and offer insights on how they can be solved.
Clearing Legislative Hurdles
The Centers for Medicare and Medicaid Services greatly lowered the bar for provisioning telehealth in the wake of COVID-19. Since then, providers have been allowed to deliver care through a larger range of platforms as long as they are not public-facing.
However, this doesn’t address the widely varying state requirements for licensing and credentialing. In general, telehealth providers must be licensed in the state where patients receive care. Only nine states currently offer special telehealth licenses that allow providers to deliver telemedicine outside their state limiting their potential scope.
Although we can expect deregulation to occur over the next few years, the timeline and the path it will take is very much up in the air. This means providers must develop platforms that are flexible enough to adapt to changing legal environments.
Overcoming reimbursement issues
Prior to COVID-19, reimbursement had been a key barrier to the widespread implementation of telehealth. Even now, reimbursement for conditions not related to the coronavirus can still be difficult.
Each state has different regulations guiding the type of services and providers eligible for Medicaid reimbursement. For example, reimbursement policies often only applied to rural areas or those within certain geographic restrictions.
Once the public health crisis has ended, many of the current flexibilities will end, putting a particular strain on smaller facilities. Overall, there must be comprehensive and holistic reform that ensures all providers get reimbursed, whether providing care in person or via telehealth.
Addressing inequality in access to care
One of the greatest benefits of telehealth is that it can facilitate care well beyond the walls of physical healthcare facilities. No longer limited by geography, mobility, or other factors, patients can receive care as long as they have an internet connection.
However, many individuals around the country do not have access to high-speed internet and/or smartphones. For example, only 69.3% of rural areas and 64.6% of tribal areas have adequate access to high-speed broadband. This directly affects patients’ ability to participate in telehealth modalities, including consultation and remote monitoring.
Likewise, many telehealth services are based on smartphone apps. Rural populations are also less likely to own smartphones compared to urban and suburban residents—71% of rural residents compared to 83%.
While 71% may sound like a good number, we’re talking about tens of millions of people, and disproportionately elderly individuals with greater needs, who can’t use telehealth for these reasons.
Providers must develop platforms that can support audio-only, offline, and alternative channels to compensate for these connectivity and device-access obstacles.
Interoperability is fundamental for the long term success of telehealth services. While the large scale adoption of electronic health records (EHR) has been one of the greatest achievements of the past decade, even that has not been with its hurdles—particularly in rural settings.
Taking this electronic health data and ensuring interoperability among disparate apps will require secure data exchange without special user effort. Second, interoperability needs complete access, modification, and use of all patient electronic health information. Finally, it must restrict information blocking or any “knowingly and unreasonably” interfering with the exchange of EHR data.
To do all of this requires the development of core standards and practices, cross-training, and significant investment in data security for all telehealth platforms across the industry.
Since the foundation of medicine, healthcare has relied on in-person interactions. COVID-19 taught everyone just how important remote care is, especially during times of infectious disease transmission.
However, even with its clear advantages, some patients remain unconvinced. How do you still deliver effective and safe care to these individuals?
As telehealth continues to expand and patients grow more familiar with it, some of this will disappear on its own. But, telehealth providers must take steps to educate patients about the specific benefits of telemedicine, explain to them how to use platforms and services, and ensure their PHI is secure.
Of all the challenges to telehealth, this is both the most difficult, yet attainable. It’s entirely in the hands of telehealth providers how well and how quickly they’ll be able to overcome this barrier.
Telehealth: Driving the Future of Healthcare
Now is the watershed moment for telehealth. As the world slowly returns to normal and some of the regulatory and reimbursements policy restrictions come to an end, whether the healthcare industry can maintain the gains that have been made the last few months remains to be seen. There is no guarantee that healthcare won’t return the way it was before the pandemic.
Now’s the time for telehealth providers and those interested in joining the market to create solutions for the issues described above that will capitalize on all of telehealth’s benefits and ensure the long term viability of this effective and absolutely vital care modality.
You can dive further into the world of telehealth in our Shine podcast. In our latest episode, four industry experts discuss the world of telehealth, the tests it’s facing, and where it’s headed in the near future.
About Ed Adamson
Ed Adamson is a Director of Strategy & Insight at Star, a global consultancy that connects insights, strategy, design, engineering, and marketing services into a seamless workflow. Adamson has 19 years of experience of brand-led innovation for some of the world’s greatest CPG brands from companies including P&G, Kimberly-Clark, Coty, GSK, Bayer, Danone, Mondelez and McCormick Foods.